Inspection on 27/10/09 for Sunrise Operations Weybridge (Assisted Living)

This inspection was carried out on 27th October 2009.

CQC found this care home to be providing an Poor 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 Weybridge... 03/02/10

Sunrise Operations Weybridge... 13/08/08

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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 Weybridge (Assisted Living) Ellesmere Road Weybridge Surrey KT13 0HY Lead Inspector Sally Hall Key Unannounced Inspection 27th October 2009 09:30 DS0000071632.V378150.R01.S.do c Version 5.3 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 Weybridge (Assisted Living) DS0000071632.V378150.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 Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunrise Operations Weybridge (Assisted Living) Address Ellesmere Road Weybridge Surrey KT13 0HY 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) 01932 871100 01932 871101 Sunrise Operations Weybridge Ltd Manager post vacant Care Home 81 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.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 with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 81. Date of last inspection 13th August 2008 Brief Description of the Service: This residential care home with nursing has been purpose built to high specifications and offers accommodation and care to 81 service users in tastefully decorated and furnished surroundings. The rooms are over three floors and there are passenger lifts for those who cannot manage the stairs. The bedrooms vary in size and some come with two rooms, these can be used for couples or can be used as a bedroom and lounge. There are a number of communal areas that service users can choose to sit or dine in. There is also an area where service users and or there families can make tea and coffee. The gardens are interesting, well maintained and accessible to those less mobile. There are plenty of seated areas for service users and their visitors to enjoy the views. The home has a concierge service at front of house for both visitors and service users living at the home. The home offers a range of activities and has a minibus for regular outings. The home currently offers 20 beds for people who need nursing care and the remaining beds are for service users who have residential care needs only. Fees for this home are divided between the accommodation and the care provision. The accommodation ranges from £693 to £1540 per week depending on the size of the room/s. The care charge is worked out on the basis of need, in half hour slots in agreement with the service user/family at the time of admission and is reviewed if those needs change. The giving of medication is also changed for those receiving residential care, no charge is made to service users receiving nursing care. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.2 Page 5 Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero star. This means the people who use this service experience poor quality outcomes. We agreed and explained the inspection process with the Team Leader at the start of the inspection and later with the appointed manager and executive director. This is the first key inspection of the service since it changed it’s registration from domiciliary care and accommodation to a residential home with nursing. A random inspection did take place on the 17th August concentrating on medication ordering, storage, administration, recording and disposal following concerns raised during safeguarding reviews. The focus of this inspection was to assess Sunrise Operations Assisted living Weybridge in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older People in relation to all key standards. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre-inspection information such as notifications sent to us by the provider of incidents, any issues raised by the public or Social Services in discussions or correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an AQAA an annual quality assurance assessment questionnaire, this provided us with information relating to what the home considers it does well, what they could do better, what has improved within the last 12 months and further plans for improvement. The AQAA was received in June 09, prior to us completing an Annual Service Review which resulted in us undertaking this site visit to the home. Survey questionnaires were also sent to the home prior to the inspection for distribution to service users, staff and other health professionals Documentation and records were read. Time was spent reading of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, staff rota, training records and recruitment records. We identified four people who use the service for case tracking, speaking with one of them whilst assessing the available information held in the home pertaining to the care provision for them. We also sampled specific information in other service users files in order to evidence common practice. In addition the Inspector met with the other service users who use the service Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.2 Page 7 and families visiting, which gave a good opportunity to observe the quality of care being provided by the home and understand the impact the care provision has on their quality of life. What the service does well: The home has a buddy scheme in operation, this is where a service user has agreed to meet and greet new service users when they come into the home. The buddy is able to answer questions about the home and explain what life there is like from their perspective. The buddy introduces the new service users to other people living in the home and explains what goes on in the home, activities, social events etc. The home has a very varied activity programme and each service user has a copy of the month’s events and activities. Service users are kept informed of any changes to the programme and encouraged to take advantage of what is on offer. As well as activities such as craft, pottery, quizzes, exercises, card games including whist and bridge, entertainers come into the home, give talks, play music or just facilitate a good old sing song. The home’s environment, furnishings and fixtures are provided and maintained at a high standard. All areas of the home and grounds are wheelchair accessible and there are lifts and stairs to the first floor. The communal areas of the home are spacious and offer various areas to sit relax or entertain in. there is a bistro where service users can make themselves and guests a drink or staff will facilitate this for them. The dining area is light and bright and looks out on to well tended garden. Here there are seating areas, planted areas giving interest all year round and a shed which is used for pottery. Service users individual rooms are well furnished however service users are encouraged to personalise them and bring in some of their own items, pictures, ornaments etc. there are a range of baths including spar spa baths and all rooms are en-suite with a shower or bath. What has improved since the last inspection? Since the last random inspection was undertaken regarding medication there has been some improvement regarding service users receiving medication prescribed. Regarding improvements re the other key areas of inspection this is the first inspection under the Care Home Regulations 2001 and the National Minimum Standards for Older People. Previously the service was registered as domiciliary care agency and was inspected under different regulations and standards therefore it is not possible to comment. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.2 Page 8 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 Weybridge (Assisted Living) DS0000071632.V378150.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 Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 4,5, 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 can not depend on the accuracy of the information given to them prior to moving in the home. Service users can be confident that they will be assessed to ensure their needs are identified. EVIDENCE: The Statement of Purpose and Service User Guide is provided by the home to prospective service users to give them the accurate information they need to make an informed choice about whether the home is right for them. Service users spoken to did confirm that they had received a copy of this and other information before spending a day at the home. However the Statement of Purpose at this home needs to be reviewed as some of the information was not clear. For example the document states that those deemed as needing nursing Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 11 care will have this provided by qualified nurses at the home. However some nursing needs are still being provided by district nurses. Nursing staff at the home only administer nursing to those service users assessed as nursing. If a service users is assessed as residential then any nursing needs are undertaken by district nurses, this needs to be fully explained in the statement of purpose to avoid the distress seen when a service user could not understand why they were waiting for an injection when there were nurses on duty in the home. The information is misleading regarding the reference to the registered manager of the home, the appointed manager is not registered and an application is not pending, as an application has not made to the commission. This was confirmed by the appointed manager. The appointed manager visits the prospective service users and completes a needs assessment. Assessments were seen on the files sampled and contained the information needed to assess the prospective service users suitability for the home and whether the home can meet the service users individual needs. This happens prior to service users being offered a place at the home. The assessment covers all aspects of care and personal information including medical history, and how that affects what they are able to do for themselves and identifies areas where they will require support. A service user is only offered a place at the home if the assessment shows the home can meet that individual’s needs, the appointed manager confirmed. Once the service user has been offered a service they are invited to spend a full day at the home to see if it suits their needs and meets their expectations. If after that they decide to come into the home the appointed manager explained they do so on a month’s trial, during which time the service user can decide if their care needs are being met and they are happy to stay. The home’s staff can decide if they are meeting the individual’s needs, a review is held and if the parties are agreeable the placement becomes permanent. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some service user’s health and wellbeing is potentially compromised by the poor records kept of the nursing care provided and by the lack of risk assessment with the management strategy to minimise that risk being in place. Service users can not be fully confident that they will be part of the an individual care planning process with their care wishes and preferences informing its formation Service users can not feel confident that the home’s policies and procedures on medication fully protect them. EVIDENCE: Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 13 Five care plans were sampled fully which included examples of both residential care and service users needing nursing care. All care plans that were seen contained evidence of individual’s needs that mostly corresponded with the care needs assessments that had been undertaken, evidence of regular review was apparent however updating of care plans was not evident in all cases. Care plans in some cases appeared to have areas of the plan pre populated with staff action and outcomes required. This was seen particularly in care plans where service users needed little care provision. All designated care plan pages make up the care plan even if the service user does not need any support in those areas. There was little evidence in many plans seen that the service users had been an integral part of their formation. Service users would benefit from the home documenting detailed nursing support needs where nurses are providing nursing care. For example, an identified pressure area was being dressed; however no detailed record of the dressings that were being administered by the nurses, or how often they needed to be changed were available. There was also little evidence of the progress of the pressure sore regarding healing. The appointed manager explained that some of the notes read were written by the skin integrity nurses however it was not possible to identify which these were. All nursing needs must be recorded in detail to ensure service users receive appropriate support, and nursing staff are clear what support is required. With out these records service user’s cannot be sure they will receive consistent nursing care and their health and wellbeing could be compromised. Two service user’s files seen contained care plans written when the service was a registered as domiciliary care agency in 2008, there has been no new assessments or care plans written since the home became a registered care home with nursing. All service users must have the appropriate up to date documentation, with their health and wellbeing being monitored and recorded. It was recommended that, care plans are signed by the service users where practicable to show they have agreed the care that is to be provided for them. As well as showing the areas of their care they prefer to attend to themselves when they can. Shortfalls in risk assessments were noted and could compromise service user’s health, welfare and safety. Current risk assessments need to contain more detail and be reviewed regularly. A number of examples were noted where risk assessment/management strategies are necessary but have not been documented, these include the risk of possible pressure areas having been identified using a Waterlow assessment. This is a recognised assessment used to assess the persons skin integrity and the level of possibility that the skin may break down and a pressure sore develop. The home must develop risk management strategies for identified risks, and these must be detailed. All Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 14 individual risk assessments must be reviewed in a timely way depending on the level of risk. The daily records made by both care staff and nurses in the form of progress notes were seen, in many cases these cross referenced with the plans of care seen. However not all the information was recorded in enough detail and it was not possible to follow the progress of treatment for example. In two service users notes no entries had been made for four to five days in October in both the care and nursing notes. Staff were unable to account for this, these were notes for service users who received high care needs and a lack of continuity in the notes could compromised their care. Staff must ensure they have sufficient dressings etc to undertake treatment in the way documented. Evidence was seen where a change in the treatment for several days was made because dressings had run out. This again could compromise the service users care. The safe handling of medicines was assessed by a Commission specialist pharmacist inspector, both as part of this inspection and at a previous inspection on 17 August 2009. They looked at the medication records for people needing different levels of support with their medicines and at the medication supplies and care plans for a selection of these people. They also observed people being given their medicines by the nursing and care staff. When we visited on 17 August 2009 the records and medicine supplies were not able to show us that all of the people living at the home were receiving their medicines as prescribed by their doctors. At this visit we found that improvements had been made and people were being given their medicines. When we visited on 17 August we found that when medicines were given to people there were gaps in the records that should be made to show that people have been given their medicines. On six occasions when we looked at the medicine supplies it showed us that the medicines were still in stock and could not have been given on these occasions to these people. On a further five occasions the medicines had gone from stock and people may have been given their medicines at these times but the records failed to show this. At this inspection we did not find any gaps in the records when medicines were given to people. When we visited on 17 August we identified two people who had medicines prescribed to be given at night but only when needed (PRN medicines). Both of these people were being given the medicine every night. No care plan was available for either of these people to describe to staff what the medicines were for and under what circumstances the medicine should be given. The home’s procedures say that people who have PRN medicines should have a protocol that provides this information. These were not available for these people. This could have resulted in these people being given medication that Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 15 they do not need. At this inspection we found that a PRN protocol had been written for one of these people but that it still failed to provide staff with information or guidance as to when the medicine should be given and when it should not. The second person still had no PRN protocol. This was brought to the attention of the service by the Commission following the inspection in August. Since no or inadequate action has been taken these people remain at risk of being given medication that they do not need. When we visited on 17 August 2009 we found that when people were identified as being allergic to any medicines this information was recorded on the personal detail sheet. Only one of five people who had allergies had this information recorded on their Medication administration records chart, despite their being a space for this to be recorded in. At this inspection we found that there had been no improvement in the recording of allergies and this information was still not being recorded on the medication administration record charts. This could result in people being given a medicine to which they are allergic. When we visited on 17 August 2009 we found that people who choose to look after their own medicines have the risks associated with this assessed. The assessments scored a level of risk but there was no indication as to how these had been arrived at nor any plan to minimise any risks. At this inspection we found that there had been no improvement in these risk assessments. This could put people at unnecessary risk of harm Medicines are given to people who use the service either by registered nurses or by care assistants who have received training in the safe handling of medicines and who have had their competency assessed. Clear and detailed procedures for the safe handling of medicines are available and accessible to staff. When we visited on 17 August 2009 we found that medicines liable to abuse, known as Controlled Drugs, were being stored in cabinets that would meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 if they were correctly secured to the wall. Additional records in the form of a Controlled Drugs register were being kept so as to readily detect any losses of these medicines. A selection was checked and the records and stocks corresponded. At this inspection we found that the cabinets were still not correctly secured. All other medication was stored securely for the protection of people who use the service. Within the care plan there is a section to be completed regarding the service users wishes in the event of death and dying. However in those seen no entries had been made. It is important that the service user’s wishes are respected in death and instructions for staff should be clear. The appointed Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 16 manager stated that staff had asked service users and families but with no response, however this contact was not documented. Service users who live in the home confirmed that arrangements are made for them to see their doctor, chiropodist and other health care professionals when they need to. Service users spoken to said they were happy at the home, several said that they like the way staff are very respectful in the way they talk to them. One said that the staff never make them feel as if they are a nuisance even when they must be busy. Another said that some days she is better than others and she likes the way she can ask for help when she needs it, but she is given time to do what she can herself. All the service users spoken to confirm that their privacy is respected and that staff knock on doors before entering, they also confirmed that staff spoke to them in a respectful way at all times. Observation of interaction between staff and service users throughout the visit confirmed that privacy and dignity is respected in the home. Potentially embarrassing information is handled discreetly and sensitively. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 17 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): 12,13,14,15. 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 benefit from being supported to make choices and have a wide range of activities available to them. Service users can feel confident overall that they are offered a well balanced diet and will be supported to eat their food where necessary. EVIDENCE: People who live in the home are supported to live their lives as they choose. Routines are flexible. There is a variety of activities on offer such as art and craft, sketching, Bridge, knitting, quizzes and exercise, which they may choose to take part in if they wish. There is activity coordinator employed in the home. The activity co-ordinator was enthusiastic about her role, and described the different activities (including outings) service users have access to. The service users have a programme showing the months planned activities, and service users are also reminded by staff on the day plus given details of any changes to the programme. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 18 A relative commented that the home is always welcoming to visitors and that staff and management are helpful. The home takes particular care to ensure that food is nutritious and takes account of specialist dietary needs. Currently the main meal of the day consists of a meal with meat or fish and a vegetarian dish. It is important that all service users regardless of their dietary needs or preferences are offered a choice, as meals are often the highlight of the day. Alternatives are available such as omelettes and there is a salad bar if service users do not like what is offered. Service users said that they enjoyed the meals and there was a choice or a salad bar where service users can help themselves. The service users also commented that they now have a dining room co-ordinator, this has improved the service. The lay out of the dinning area has also been changed by the co-ordinator and this has made it easier for service users to get the tables they choose to sit at. A visitor on the day joined their mother for lunch; service users said that this is never a problem. We joined the service users for lunch; the meal was presented and cooked well. All the service users around the table enjoyed the meal, and choice of beverages. The dining room is light and welcoming with tables attractively set, although service users can choose to take their meals in their rooms. Currently the home only records the amount of food eaten in some daily records kept in the home. It is important to keep a record of what meals have been eaten by service users in the home. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 19 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): 16,18 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. The home has an effective complaints system in place and service users can be confident their complaints will be taken seriously. Service users are protected by adult safeguarding policies and procedures EVIDENCE: The home had a written complaints procedure, which was seen. Feedback received and comments made within service users surveys confirmed they were aware of the contents and felt free to voice their concerns. In the AQAA, Annual Quality Assurance Assessment state by June 09 the home had received 24 complaints, all had been dealt with within the time scales. Since then staff confirmed that there had not been any complaints recorded Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 20 The Whistle blowing policy and procedures for staff and safeguarding adult policy for service users were in place. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. In the June 09 AQAA stated that there had been six safeguarding referrals however there have been none since then. Full training has been provided in safeguarding for all staff as part of the induction that all staff undertake. Competency in the subject is checked as part of that induction. The home is aware that safeguarding training needs to be refreshed every three years for all it’s staff. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 21 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): 19,26. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can be confident that they will be living in clean, safe and well maintained home, which offers a choice of private personal accommodation and communal areas where service users can sit. With all areas being furnished and decorated to a high standard. EVIDENCE: The home provides a choice of accommodation and this includes, single occupancy bedrooms which have en-suite bathrooms, Companion suites/bedrooms can be occupied by two people who chose to share Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 22 toilet/bathing facilities. Bedrooms are carpeted and decorated to a very high standard and meet the National Minimum Standards re furniture requirements. Service users rooms are lockable and service users may have their own key. Each service user’s room has a window which they can open and see out of but is restricted for safety. Each suite has a heater which can be adjusted by the service user. There are also communal toilets with disabled access and spa baths around the building. The communal areas around the home can be used by all service users and include a tastefully decorated dining area, a number of lounge areas, and bistro where service users and visitors can make drinks during the day. There are other seating areas about the home that the service users can choose to sit in. Service users and family members spoken with said that the home is always very clean and there are never any unpleasant smells. There is an area where activities often take place. There are garden areas which can be seen from most of the home’s windows, all are well maintained and give a pleasant outdoor space consisting of well maintained planted beds, grassed and paved areas with seating and is accessible to all service users. The appointed manager confirmed the home has the equipment necessary to provide appropriate nursing care, with nursing beds, specialised mattresses and other items that may be required. The home has policies and procedures for infection control, and staff have access to PPE (Personal Protective Equipment) such as gloves and aprons. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 23 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, 30. 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 can feel confident that their care, social and emotional needs will be met by care and nursing staff in sufficient numbers who have the skills, knowledge and training to meet those needs. Although the home has yet to meet the target numbers of care staff with a National Vocational Qualification it is working towards it. EVIDENCE: The ratios of care staff to service users are determined according to the assessed needs of service users. Following discussions with the staff, a review of the rota and observations made during the inspection. The Commission were of the opinion that sufficient care staff and nurses were on duty to support service users to meet their personal needs. A check has been made of the training that has been undertaken by the care staff at the home, and it found that from information given by the appointed manager and the executive director the standard of staff training was good overall with the majority of care staff completing basic courses, and all new staff undertaking induction training that meets the requirements of the Skills for care Council. However at present the home has not achieved at least 50 of care staff with the NVQ (National Vocational Qualification) Level 2 or above. However of the Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 24 37 staff employed, 13 care staff have the award, and currently 11 care staff are undertaking the award. Once the 11 care staff have successful attained the award they will have exceeded 50 per cent. The home does have a commitment to NVQ’s and currently also have catering staff undertaking the award. The home employs just 4 registered nurses and the shortfall is made up of agency nurses. To ensure continuity of care they have now arranged for the same three agency nurses to have a short term contract with the home. The appointed manager was aware of the need to ensure that all nurses attend training through the year as required by their NMC registration. The home employs a number of ancillary staff who work as cleaners, catering staff, gardener/ maintenance staff. Thus allowing care staff and nurses the time to meet the needs of service user’s. It was not possible to see the staff files to evidence recruitment on the day of inspection as the administrator was not available. The home does have a recruitment policy and procedure when followed would ensure the safety of service users living at the home. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 25 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, 32, 33, 37, 38. 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 and or their relatives can be confident that their views and opinions effect how the home is run but cannot be fully assured that service users best interests are wholly safeguarded by appropriate risk assessment/ management or nursing documentation. EVIDENCE: The home currently has a manager appointed by the registered provider who is a qualified level one nurse. However we have not currently received an application for them to become registered. It is an offence under section 11 of Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 26 the Care Standards Act 2000 for a person to manage an establishment or agency without being registered in respect of it. An application needs to be made a priority in respect of this. Quality assurance was discussed and the views and opinions of the service users are sought in a number of different ways. As well as annual questionnaires organised by the organisation based in America, the home has regular meetings with the service users about the running of the home and their wishes concerning meals and entertainment for example. Service users spoken to confirmed a great deal of satisfaction in living at the home and felt confident that the staff and management valued their views and opinions. The service users buddy scheme where a service user greets new service users also gives service users someone who they can discuss life in the home with. The buddy said that she passes on people’s views if they do not feel confident to do so. There was evidence that Regulation 26 visits (Statutory documented visits by the provider to monitor standards within the home) are taking place. This requires the provider to monitor the conduct of the service to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards and requirements of the legislation. The appointed manager confirmed regulation 26 visits are taking place, and she stated that some of the short falls had been recognised during those visits. The home has developed a health and safety policy to meet health and safety requirements and legislation. However currently there is a shortfall in risk assessment documentation regarding the service users, and management has not made sure that they are protecting service users through this process. Records were not comprehensive, lacking sufficient detail particularly pertaining to service users nursing care. This is necessary to ensure that nurses are aware of the up to date instructions regarding the nursing support needed for each individual service user. This could compromise service users health, welfare and safety. The home’s maintenance person ensures that regular checks and servicing of fire safety equipment / emergency lighting is undertaken at the required frequency. The COSHH (Control of substances hazardous to Health) file which details the first aid information necessary if there is an accident was seen. The AQAA (Annual quality assurance assessment) indicated that maintenance certificates such as boiler, gas and electric safety checks have taken place in a timely way. Fire emergency instructions were explained by a staff member at the beginning of the visit. Whilst it is recognised that this is the first inspection of the home since it moved away from providing domiciliary care to service users living in the Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 27 accommodation to a residential home with nursing. It is of concern that the management have not fully understood the implications. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 28 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 1 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 10 11 4 x x x x x x 3 STAFFING Standard No Score 27 28 29 30 1 3 2 3 3 x 2 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 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X X X 1 3 Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 29 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 Requirement The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework, which includes monitoring. All Controlled Drugs must be stored in a cabinet which meets the requirements of the Misuse of Drugs(Safe Custody) Regulations 1973 The registered person must make available to service users an up to date statement of purpose which reflects the current services that are available and keeps all information under review. Ensure information about services provided within the Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 30 Timescale for action 20/12/09 2. OP9 13 20/12/09 3 OP1 4 (1)a,b,c, Schedule 1. 20/12/09 4 OP7 12 (2)(3) document is clear and easily understood regarding the residential care/nursing care offered by the home and to whom they relate. The registered person must ensure all service users have a plan of care detailing their needs, wishes and preferences regarding the support they wish to receive. 20/12/09 5 OP7 15 (1)(2) 14 (2)a,b, To support service users to be an integral part of the formation of their plan of care to include their needs and wishes. The registered person must 20/12/09 ensure the assessment of service users is kept under review and is revised when their needs change To support service users with their ongoing changing care/nursing needs. 6 OP8 13.(4)c, Where risks are identified, an assessment along with a management strategy to minimise that risk is documented and kept under review. To minimise the risks to service users wellbeing. The registered person shall ensure records are maintained in respect of service users as detailed in schedule 3, To ensure service users receive the care and support as appropriate, ensuring suitable detailed records are kept within the home that are kept up. To date, particularly regarding the nursing treatment and care. 20/12/09 7 OP37 17 Schedule 3 20/12/09 Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 31 10 OP31 18 The registered person must ensure that the appointed manager of the service submits an application for registration with the Commission 20/02/10 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 Refer to Standard OP7 Good Practice Recommendations That service users be asked when possible to sign care plans once they have been written with, and agreed by them. Sunrise Operations Weybridge (Assisted Living) DS0000071632.V378150.R01.S.doc Version 5.3 Page 32 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. 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. 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