CARE HOMES FOR OLDER PEOPLE
Sutton Lodge Nursing Home 87 Oatlands Drive Weybridge Surrey KT13 9LN Lead Inspector
Mavis Clahar Announced Inspection 26th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sutton Lodge Nursing Home Address 87 Oatlands Drive Weybridge Surrey KT13 9LN 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 222184 BUPA Care Homes Limited Ms Janice Anne Betchley Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability (5), Physical disability of places over 65 years of age (5), Terminally ill (2), Terminally ill over 65 years of age (2) Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Of the accommodated in the home, up to 5 may fall within the category (PD) Physical Disabilities (from the age of 40 years) or PD(E) Physical Disabil. Of the accommodated in the home, up to 5 may fall within the category (PD) Physical Disabilities (from the age of 40 years) or PD(E) Physical Disabilities over 65 years. The age range for service users falling within the category OP (Older People) is 60 YEARS & OVER 28/06/05 2. Date of last inspection Brief Description of the Service: Sutton Lodge is a privpate care home that provides nursing care, owned and managed by BUPA. Service provision is predominantly for older people from the age of sixty years, with five places for physically disabled adults from the age of forty years. This Edwardian house has been tasefully converted and extended over the years to provide a comfortable, welcoming home with modern equipment and facilities. There are car parking facilities to the front of the premises and an enclosed, mature furnished garden to the rear. The home is conveniently located near to shops and all community amenities in the small town of Weybridgie. Bedroom accommodation is arranged on the ground, first and second floors, accessible by a passenger lift. Most bedrooms have en-suite facilities and are predominantly single rooms. The home has comfortable spacious lounges and a separate dining room. A conservatory affords an adittional sitting area overlooking the garden. A full time nurse manager and deputy are employed. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year March 2005 to April 2006. This announced inspection took place on the 26th September 2005 and lasted four and three quarter hours. This inspection was well advertised in the home, therefore service users and their relatives and all staff at the home had the opportunity to speak with the inspector if they so wished. The first part of the inspection was spent in discussion with the newly appointed manager for the home, outlining the format the inspection would take; followed by random review of policies and procedures, service users files, care plans and assessments. The second part was spent talking to service users and their visitors, and staff. One visitor in particular appeared pleased to see the inspector and said she remembered the inspector from the June inspection when she had a long chat with the inspector about the positive care her relative is receiving at the home. The final part of the inspection was spent touring the home and grounds and giving feedback to the manager about the findings of the inspection. The grounds and gardens were looking lovely and it was evident the recommendations pertaining to the garden was implemented. All the service users spoken to were complimentary about the home, and did not find the quality of care they received diminished during the period the home was without a manager. No requirements or recommendations were made on this inspection. What the service does well:
The inspector observed good relationships between service users and carers, between visitors and management. Assessment of service users health and care needs including risk assessments are fully documented and where required are signed and dated. Service users spoken to were please with the level of privacy given to them by care staff. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Not assessed. EVIDENCE: Standard 6 does not apply to this home as service users requiring intermediate care are not admitted to this home. For information on standards 1 2 3 4 please refer to the report of 28th June 2005. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 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 the following standard(s): 10 Personal support and care are offered in this home in a way that promotes and protects service users privacy and independence. EVIDENCE: Review of service users files, care plans and daily work sheet and in discussions with service users it became apparent that care workers are diligent in maintaining the dignity and privacy of the service users. One service user said “my personal care is done with care and understanding. The nurses here are so kind, nothing is too much for them to do for you”. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Service users links with the community and their relatives are good, and this link supports and enriches their personal, social and religious lives. EVIDENCE: The home employs a full time activities coordinator who provides a wide range of activities for the service users, in which they have the option to participate or not. No pressure is put on a service user to take part in any of the activities. Family and friends of the service users visits as often as they are able, and some service users are taken out to lunch with their family. The spiritual needs of the service users are met by the Church of England Vicar visiting the first Tuesday of every month and by the Roman Catholic Priest visiting once per month also. Every Sunday the service from the local C/E church is taped and is then played back to the service users on the following Sunday morning. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 These standards were assessed at the last inspection. EVIDENCE: For information on these standards please refer to the report of 28th June 2005. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The standard of the environment in this home is good providing service users with an attractive and homely place to live. EVIDENCE: On the day of inspection the home presents as clean and tidy with no offensive smells. The grounds are well maintained, safe and accessible to the service users. Service users and their relatives spoken to on the day all agreed this is a good home to live and visit. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 30 Evidence gathered during the inspection confirmed that the home meets each of the assessed standards. EVIDENCE: Random sample of care workers files and discussions with care workers and the manager demonstrated that care workers are employed based on the home employment policy, which underpins the equal opportunities act. Care workers are knowledgeable about the home’s policies on recognising and reporting any incident of abuse, and they are confident the manager will utilise the policies on whistle blowing to protect the staff member making the report. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 35 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff spoken to demonstrating an awareness of their roles and responsibilities. EVIDENCE: Service users and their relatives spoken to on the day of inspection spoke highly of the new manager. The manager has implemented staff changes within the home, which are supported by the care workers. The home does not take responsibilities for the bulk of the service users finance. Their relatives or social services manage Service users finance. The home is responsible for the pocket monies of those service users who choose to ask the home to manage their pocket money. Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X
X Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Sutton Lodge Nursing Home DS0000017647.V249917.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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