Inspection on 02/08/05 for Sunset Lodge

This inspection was carried out on 2nd August 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

Sunset Lodge 03/04/07

Sunset Lodge 17/01/06

Sunset Lodge 17/01/05

Sunset Lodge 21/10/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sunset Lodge Pembury Road Tunbridge Wells Kent TN2 3QT Lead Inspector Gary Bartlett Unannounced 02 August 2005 14:00 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 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. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sunset Lodge Address Pembury Road Tunbridge Wells Kent TN2 3QT 01892 530861 01892 531656 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Salvation Army Mrs Cherildene Cecilia Umasanthiram CRH Care Home 22 Category(ies) of Old age (22) registration, with number of places Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedroom 56 currently in use on 18/11/2002 will be registered only for the service user whose D.O.B. is 28/07/1923. 2. The Home has 11 bedrooms over 16sq.m of which 2 can be used for double accommodation at any one time. When so used, the total number of service users will not exceed the registered numer of 22. Date of last inspection 17 January 2005 Brief Description of the Service: Sunset Lodge is owned and operated by the Salvation Army. It is a large detached property on three floors, with a shaft lift and stair lifts to all floors and stands in its own grounds. It was previously a private residential house and was converted for use as a residential home for the elderly in the 1940s and was refurbished in 1979. It is registered for 22 service users. All rooms are currently used for single occupancy although 11 would be suitable for double accommodation.Sunset Lodge is located on the outskirts of Tunbridge Wells where there are the usual facilities of a town. There is access to public transport close by and the nearest doctors surgery is approximately 2 minutes walk away. Space for car parking is available and there are spacious gardens for service users to use. The Home’s staffing team comprises the Manager, Senior care staff and care staff that work a roster that gives 24-hour cover. The Home also employs other staff for catering, domestic, administration, training co-ordination and maintenance tasks. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission was represented by Gary Bartlett, Regulatory Inspector, who was in Sunset Lodge from 2.00 p.m. until 4.50 pm. During that time the Inspector spoke with some residents, a visitor and staff. Parts of the Home and some records were inspected. The focus of the inspection was to assess progress made to meet notified required and recommended actions in the last inspection report. What the service does well: What has improved since the last inspection? What they could do better: Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 6 Care planning, recording and risk assessments must improve so staff know what to do for each resident. Appropriate sluice facilities must be provided to maintain infection control. External parts of the Home must be improved and made safe. To promote residents’ safety, there must be a staff member trained in emergency first aid on each shift. Staffing levels must be reviewed to make ensure they are adequate for residents’ identified care needs to be met. 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. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 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 standard(s) These Standards were not inspected. EVIDENCE: Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8, 10 and 11 The care plans were not consistently up to date to provide staff with the information needed to meet all the residents’ needs. Residents safety would be better ensured by the recording of risk assessments in response to incidents. Staff treated residents with respect and maintained their privacy and dignity. EVIDENCE: Two care plans were inspected in detail. Although there was an improvement in the plans, one was not reflective of the resident’s observed current needs. Risk assessments had not been reviewed or recorded as a result of recent incidents. Daily records were not being consistently made and many of those seen were not informative. Some were directive with little or no explanation. It was not always evident that appropriate health care professionals had been involved in decision-making. Staff acknowledged this. It was important for residents’ welfare that necessary and current information was recorded and readily available to inform staff, especially as the Home had to use agency staff sometimes. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 10 From observation and discussion with residents and a visitor, it was clear that staff treated residents with respect and promoted their privacy and dignity. Residents could meet with visitors and make telephone calls in private. The Manager stated it had been arranged for 2 staff to attend a training course concerning terminal care and bereavement and further staff would attend as courses became available. Care plans clearly indicated resident’s last wishes. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 and 14 Residents enjoyed routines of daily living and activities that were flexible and varied to suit their preferences. Where practicable, residents could participate in local community activities and their autonomy and choice was promoted. EVIDENCE: Staff spoken with were aware of the rights of residents to have the opportunity to have choice in daily routines and activities. The Salvation Army owned the Home and prayer meetings were held daily. Residents confirmed they chose whether to attend the services or not. A notice board in the entrance hall was seen to include details of forthcoming activities that the Home had arranged. The Home had a minibus. The residents spoken with were very clear that they considered the activities available to be consummate with their wishes. Some residents sometimes stayed with friends and family for weekends etc Residents told the Inspector that visitors could be received at any reasonable time, although it was preferred for there to not be visitors after 8pm. Meal times were set, but a staff member confirmed that these could be altered if required or packed lunches provided if the resident was going out. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 12 The Manager explained that the home did not handle the financial affairs of any of the residents, but did sometimes hold small amounts of cash for them. The financial records were not inspected on this occasion. A senior staff member stated that residents could have access to records held about them but few would have a wish to do so. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 13 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 standard(s) These Standards were not inspected. EVIDENCE: Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 21, 23, 24, 25 and 26 The standard of the environment within the Home was generally good providing residents with a comfortable place to live. The outside of the building was shabby in places and some parts were poorly maintained and potentially put residents at risk. Residents’ health, safety and comfort continued to be compromised through the inappropriate position of a sluice. EVIDENCE: Those parts of the Home inspected were generally clean and free from unpleasant odours. It was seen that some internal repair work had been carried out where required. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 15 The Home continued to be generally well maintained internally. As recorded in the last two inspection reports, parts of the exterior were in need of decorating and the safety of the balcony to two first floor bedrooms needed to be ensured. Also reported previously was the potential risk posed to residents by unsuitable sluicing arrangements. There were records that indicated these matters had been reported to head office but they had still not been resolved. The Inspector advised that continued failure to comply with the requirement for the sluice to be appropriately sited and for the external parts of the Home to be made safe within the given timescales could lead to enforcement action being taken. Residents and staff told the Inspector they considered the bathing and toilet facilities to be adequate and conveniently sited. The bedrooms seen were generally well decorated and were clean and comfortable. Several residents spoken with said that they were content with their rooms and were happy to have been able to bring in some of their own furnishings. The Home was centrally heated throughout, although some residents in the lounge mentioned they felt chilly as the windows were open. As one resident said “ staff are mobile you see and don’t realise how cold it is for us”. Staff were not in the lounge at the time and were later seen to close the windows when advised of this. The temperature of the hot water was tested at several outlets and was at an appropriate temperature and residents’ safety had been better promoted by the fitting of a thermostatic control valve to the hot water tap used by the hairdresser. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing levels must be reviewed to ensure there are enough staff on duty to meet residents’ needs. EVIDENCE: Like many Homes in the area, Sunset Lodge continued to have difficulty in recruiting a full complement of staff and relied on agency staff to maintain adequate staffing levels. Residents and a visitor spoke very highly of the care staff. They said staff were generally available when required but there were times when staff were very busy elsewhere in the Home. This was confirmed when a resident got into difficulties in the dining room and staff were not in the area to hear the cries for help. It was also said that when the Kitchen Assistant had a day off, care staff were responsible for preparing tea and clearing up afterwards in addition to their usual duties. The staff rota seen did not indicate additional staff were brought in. Residents were potentially at risk during these times. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The protection of the residents’ health, safety and welfare was not consistent potentially putting them at risk. EVIDENCE: The requirements for improved risk assessments and infection control are described elsewhere in this report. The Manager described how a formal staff supervision programme had been implemented. Care staff were supervised every 2 months and ancillary staff had an annual appraisal. Staff were seen to be diligent in ensuring COSHH requirements were adhered to and those spoken with had a sound understanding of emergency procedures. Records indicated there was not always a staff member trained in emergency first aid procedures on duty. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 18 Although the Manager said a supply of protective coats and hats had been bought for staff entering the kitchen whilst meals were being prepared, the hats could not be found at the time of inspection. A staff member confirmed there were “some hats, somewhere”. Consequently, the Home could not ensure food hygiene standards were maintained to protect residents. Records of maintenance and safety checks were not inspected. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x 1 x 3 3 3 1 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x 3 x 2 Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15(2) 17 Schedules 3 and 4 Requirement “The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review” in that: 1. Care plans must be accurately reflective of service users current needs. 2. Records of care must be kept more consistently and be more informative. Progress was being made with this but this remained a requirement from previous inspections The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be recorded in response to incidents and deteriorating changes in situation. “The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated (and shall Timescale for action Care plans to be up to date by 1 November 2005, if not sooner, and maintained thereafter 2. 7 13(4) 3. 38 13(4) Risk assessmen ts to be up todate by 1 November 2005, if not sooner, and maintained thereafter Action plan to be received by CSCI by 1/09/2005 Page 21 Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 4. 19 13(4) 23(2) 5. 27.4 18(1) make suitable arrangements for the training of staff in first aid)” The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated “The registered person shall having regard to the number and needs of the service users ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally” in that the exterior fittings and paintwork must be made good where required. The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that at all times suitably qualified and competent and experience person are working at the home in such numbers as are appropriate for the health and welfare of service users in that a review of staffing levels must be undertaken. To be completed by 31 November 2005 if not sooner. Action plan to be received by CSCI by 1/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 11 38 Good Practice Recommendations It is recommended all care staff attend specific training courses concerning terminal care and bereavement It is strongly recommended the supply of protective hats for staff entering the kitchen whilst meals were being prepared is to hand for use. Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Sunset Lodge H56-H06 S36527 Sunset Lodge V236688 020805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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