Care Home: Sunridge Court

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What the care home does well There is a strong emphasis on promoting and maintaining Jewish culture and faith, which is important to the people who live in the home. The home is very comfortable and attractive, and the facilities enable residents to meet together to socialise, or to meet relatives in private. No-one is admitted to the home until their needs have been assessed and potential service users are given good information about the service and what to expect when they move in. The residents are able to participate in the smooth running of the home through various meetings, a comments box and annual audits of their views. The relationship between the people who live in the home and the staff is very positive, and staff are diligent in ensuring that the residents` healthcare needs, which are set out in individual care plans, are attended to by the GP and other healthcare professionals.There is an excellent programme of stimulating activities provided within the home and there are good links with the local community. The residents are very complimentary about the standard of their meals and the home environment. The people who live in the home are confident that any concerns or complaints are taken seriously and responded to promptly. There are robust staff recruitment procedures and there is a strong emphasis on staff training and development. The manager is well qualified and experienced at running the home, which she does efficiently. There are good systems in place to safeguard residents` financial interests and to ensure that their health and safety is protected. What has improved since the last inspection? All residents now have a care plan and a risk assessment, within twenty-four hours of admission to ensure that staff are aware of the residents` immediate needs. An audit of the quality of the service has been carried out with the residents and their representatives and an annual business and financial plan for the home has been drawn up and is available for inspection. The plan reflects how the service is to be developed over the next two years. The hot water supply in the home is regularly monitored to protect residents, staff and visitors from the risk of injury. CARE HOMES FOR OLDER PEOPLE Sunridge Court 76 The Ridgeway Golders Green London NW11 8PT Lead Inspector Tom McKervey Key Unannounced Inspection 09:45 2nd January 2008 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunridge Court Address 76 The Ridgeway Golders Green London NW11 8PT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8458 3389 020 8455 0902 Sunridge Housing Association Mrs Pamela Venita Darroux Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Eight specified service users who are diagnosed with dementia may remain accommodated in the home for so long as the home is able to meet their needs. The home must advise the registering authority at such times as any of the specified service users vacates the home. 10th May 2006 Date of last inspection Brief Description of the Service: Sunridge Court is owned by Sunridge Housing Association, which provides care and support for up to 46 older people, male and female, from the Progressive Jewish Community. The building has three storeys, and residents’ accommodation is on the first and second floors. All rooms have en-suite facilities. The majority of this group of service users live quite independently and have a very active lifestyle. There is a ten-bedded area, referred to as the care unit, on the lower ground floor of the home, which accommodates more frail service residents who require more support. Some of these residents have dementia. There is a separate small dining area in the care unit, but these residents are welcome to use all the facilities throughout the home. There is a large dining room, a lounge and conservatory, on the ground floor. The administration area and an office are situated on the third floor. There is some car parking at the front of the building and there is a large attractive garden at the rear of the premises. The home is situated in a pleasant area of Golders Green, and shops, restaurants and other amenities are a short distance away. The home is easily accessible by public transport. The fees for residential care range from £460 to £655 per week and from £605 to £720 for respite care. Following Inspecting for Better Lives, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed in six and a quarter hours. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. At the time of the inspection, the home was fully occupied and there were no vacancies. The registered manager was present throughout the inspection and fully cooperated in the process. Before this inspection, the manager sent an AQAA, (Annual Quality Assurance Audit), to the Commission. This document is a self-assessment of how the home meets the National Minimum Standards. Against each standard, the home is asked to provide evidence about what the home does well, what they could do better, how they have improved in the last 12 months and what their plans are for improvement. The AQAA contained good information about the service and I discussed with the manager where the information could be further improved. The inspection process consisted of a tour of the premises, including visiting some residents in their bedrooms. In all, some twelve residents were spoken to about their experience of living in the home. I interviewed several staff individually and attended the staff handover, after which, I had a discussion with three other care staff. These interviews were conducted independently of the manager. Records and other documents relating to the efficient running of the home were examined. As part of the inspection process, the Commission sent questionnaires to the residents’, nine of which were returned with comments from people who live in the home. The comments were very positive about the home and are referred to in this report What the service does well: There is a strong emphasis on promoting and maintaining Jewish culture and faith, which is important to the people who live in the home. The home is very comfortable and attractive, and the facilities enable residents to meet together to socialise, or to meet relatives in private. No-one is admitted to the home until their needs have been assessed and potential service users are given good information about the service and what to expect when they move in. The residents are able to participate in the smooth running of the home through various meetings, a comments box and annual audits of their views. The relationship between the people who live in the home and the staff is very positive, and staff are diligent in ensuring that the residents’ healthcare needs, which are set out in individual care plans, are attended to by the GP and other healthcare professionals. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 6 There is an excellent programme of stimulating activities provided within the home and there are good links with the local community. The residents are very complimentary about the standard of their meals and the home environment. The people who live in the home are confident that any concerns or complaints are taken seriously and responded to promptly. There are robust staff recruitment procedures and there is a strong emphasis on staff training and development. The manager is well qualified and experienced at running the home, which she does efficiently. There are good systems in place to safeguard residents’ financial interests and to ensure that their health and safety is protected. What has improved since the last inspection? What they could do better: The Statement of Purpose needs to be updated to include information to potential service users about the admission criteria to the care unit, and the fact that couples can be accommodated in the home. An appropriate means of transferring a specific resident from their bed must be provided to safeguard the health and safety of the resident and the staff. The manager should seek advice from the G.P and/or the pharmacist about the appropriate time for residents to receive their medication, and an accurate record of the medication administered to residents must be maintained. This is to minimise errors and protect residents’ wellbeing. The water tanks must be tested annually to protect residents and staff from Legionella bacteria. Please contact the provider for advice of actions taken in response to this Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service, looking at records and speaking to residents. The home understands the importance of providing good information when choosing a care home. People are only admitted after a comprehensive assessment of their needs by a skilled person to ensure that the home is appropriate, and prospective service users are given the opportunity to spend time in the home. All new residents are given a contract, detailing the terms and conditions and the fees charged. EVIDENCE: There is a Statement of Purpose and a Service User Guide/House Rules, which provide information about the service, including staffing arrangements and how to complain if necessary. However, the Statement of Purpose needs to include information about the criteria for admission to the “care unit” and the fact that couples can be accommodated in the home. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 10 I received a written comment from a resident who said; “The brochure gave only a brief outline of the facilities etc, but there is much, much more that is done for us in this lovely home.” Another said; “ Having visited many other homes, this one is quite unique, especially as far as the cost is concerned”. I sampled the records of six of the most recent people who were admitted, five of whom funded their care. Contracts had been signed by these residents, which detailed the service to be provided and what the fees covered. One person was funded by a local authority, with whom the home had a contractual arrangement via a care manager. At the time of the inspection, there were no vacancies. The trust board has a policy whereby members of the committee assess potential service users who are living at home, and the manager also carries out her own assessment. All the residents had been assessed by the manager before admission, to ensure that the home was appropriate for their needs. Residents told me that they had visited the home prior to moving in. Some people had had respite care at the home previously and then decided to live there permanently. The home does not have double rooms, but couples can be accommodated in adjoining rooms. During the inspection I met two married residents who said they were happy with the arrangements made for them. Sunridge Court enjoys a very good reputation in the Jewish community, and several residents and relatives who were spoken to, said that they had learned of the home by word of mouth. The home only admits people from the Jewish community, which meets the religious and cultural needs of the residents, for example, by providing a synagogue within the home. There is a separate area in the home, referred to as the care unit, for the care of more frail residents, some of whom have dementia. However, these residents also have access to all parts of the home, including the dining room and lounges. A resident commented in a questionnaire; “When you read in the papers how residents are ill-treated in some care homes, how I wish that those in charge could come and see how Sunridge Court is run; in fact it would be a good idea to make a film about us to show elderly people that the words, “I have to go into a home” would not fill them with dread. Being elderly is not the end of their lives, almost a new beginning and they must be shown this”. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including examining records and observing residents’ care. The health, personal and social care needs of residents are set out in an individual care plan, which is regularly reviewed to ensure that needs are being met. At all times, residents are treated with respect and personal care is provided in a dignified manner. However, more care needs to be taken about recording administration of medicines to minimise the risk of harm to residents. EVIDENCE: I sampled six care plans. In all cases, these were appropriate and provided guidance for staff in how to meet residents’ needs. The care needs that were assessed included, physical, emotional, mental health, social, recreational and spiritual. Overall dependency ratings were also used as part of the assessment. The care plans were reviewed monthly and any changes in the person’s needs were recorded by the key worker. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 12 The manager told me that the home had recently changed the G.P service to another practice. This had been because of dissatisfaction from residents and relatives about the previous service. Feedback from questionnaires from residents was positive about this change, which had been effected with minimal disruption to the residents care. I saw healthcare appointments with the G.P and other professionals, which were recorded in a book and in individual case files. A resident commented about the quality of the G.P service: ”If you had asked me last year, I would have emphatically said no, but since the change to the new medical centre, the answer has changed to so far, “always”.” At the time of the inspection, the residents appeared healthy and well cared for, and no one had a pressure sore or was bed-bound. I spoke to twelve residents about their experiences of living in the home, particularly about their care. They spoke highly of the staff and said that they were always treated with respect and dignity, especially when personal care was being provided. A resident commented in a questionnaire; “I have angina and these attacks are quite frightening, but when I ring the emergency bell, a carer always comes”. My observation of the interactions of staff with residents, were that they were courteous and there was a very relaxed and friendly atmosphere in the home. The records for the administration of medicines in the care unit were examined. The home has recently changed their pharmacy supplier. Medication is supplied in blister packs. Most staff had been trained in the administration of medicines or were currently on this course. Medication was safely stored and the temperature of the medication cupboards was being monitored. However, I noted that there were a few gaps in the medication records where staff had not signed, or medication had not been given. I spoke to the managers about this. They said that sometimes, an 8am medication was withheld because the resident was still asleep or had refused it, and this might be given at a later time. However, this might be too near a midday dose, which could cause an adverse reaction if both medications are given. I advised the manager to seek advice about this matter with the G.P and/or the pharmacist and I have made a requirement for the home to maintain accurate records. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The service actively promotes the rights of individuals to make informed choices, including maintaining family and personal relationships. Meals are varied and nutritious and cater for the residents’ cultural and dietary needs. EVIDENCE: Residents described living in the home as equivalent to living in a hotel, with no restrictions. They described the range of choices available to them, including when to rise and go to bed, choice of meals, going out, and whether or not to join in activities. The home has an activities coordinator who is a member of the committee and who takes a lead in organising the activity programme. This includes weekly sessions of musical movement and reminiscence therapy, provided by an occupational therapist. Bingo sessions and quizzes are organised by the residents themselves and entertainment is also provided by outside Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 14 entertainers. Children from local schools visit the home and trips are organised to places of interest. The residents’ daily records show that some play bridge and go out for walks and visit local shops and restaurants. Jewish religious holidays are observed and there is a synagogue in the home. I observed staff discussing current affairs with the residents. Two residents who have dementia, have one-to-one care, which is separately funded by their relatives to so that they can have regular stimulation. The home has now got Sky television, which residents can subscribe to if they wish to view in their rooms. They also have telephones in their rooms where they can make and receive private calls. I saw several residents reading books and newspapers and there were plenty of notices on the residents’ notice board about interesting events. Regular meetings are held between residents and staff to discuss activities in the home, and one meeting is dedicated to catering, which the cook attends. There is an open visiting policy in the home and visits by friends and relatives are recorded in the visitors’ book. I observed the residents having lunch, which was fish and chips. The food was nice and hot and attractively presented. The menus showed a good variety of meals with plenty of choice. There are forms are in the dining room, for residents to request alternative choices to the planned meals and the people I spoke to, were generally very satisfied with the meals. They also stated that they could have meals in their rooms if they preferred. A resident wrote the following; “Occasionally there is a meal that I don’t like, but there are alternatives.” The kitchen was very clean and well equipped and the fridges and freezers were well stocked, with food being appropriately dated and labelled. Meals are prepared, adhering strictly to Kosher tradition. At the time of the inspection, I was informed by the cook that no residents were on special diets. The dining room is a pleasant environment to eat in and there are side tables containing various condiments to supplement the meals. Residents have fridges in their rooms and there is a fridge in the dining room for storing personal items of food. All of these elements contribute to this standard being exceeded. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including speaking to residents and staff. Complaints are taken seriously and residents are confident that concerns are properly investigated and responded to. The staff are aware of, and are trained in the subject of abuse, so residents can be assured that their best interests are protected. EVIDENCE: The home has an appropriate complaints procedure, including contact details for the Commission for Social Care Inspection. The complaints log showed that all complaints by the residents had been addressed and resolved satisfactorily within appropriate timescales. Staff have attended training in adult protection and those to whom I spoke were aware of their responsibilities to report suspected abuse. The staff have signed a form as evidence that they have read and understood the “Whistleblowing” procedure about reporting abuse. All the residents I spoke to were very complimentary about the staff and particularly the manager, who they said took their concerns seriously and took prompt action to address them. A typical comment was; “The home is run by an excellent Head of Home. She has a good sense of humour and always tries to answer your queries and listens to what you have to say”. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 16 Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including visiting all areas of the home. Residents live in a safe, clean, well-maintained environment, and they are able to have their own possessions around them. There are several areas where people who live in the home can socialise together or sit in private with their relatives if they wish. The home is generally well equipped, but an appropriate means of transferring a specific resident is needed, to ensure that theirs’ and the staffs’ health and safety is safeguarded. EVIDENCE: I carried out an inspection of the premises. The home was generally well maintained and there was a good standard of décor throughout the building. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 18 Entrance to the home is protected by CCTV, and entry is gained by ringing the door bell. There is a passenger lift to all floors and the care unit has a lift to the main home for wheelchairs. The main dining room has been redecorated and new curtains have been provided in two main lounge areas. The furniture and fittings throughout the home were of a good standard and the home was very clean and smelled fresh. There is a laundry in the care unit and another one in the main part of the home, both of which have appropriate equipment for soiled items. I visited several bedrooms, all of which have en-suite facilities. The bedrooms were comfortably furnished and there was evidence that people who live in the home are able to bring personal furniture and other personal possessions with them. All the residents I spoke to, liked their rooms. Hoists are available to support residents being transferred from bed/ toilet etc., however the staff informed me about a problem in one person’s bedroom where they could not use the hoist to transfer the resident because the bed was too low for the hoist to go underneath. The staff said that they were having to manually handle the resident, which is not safe practice. I discussed this issue with the manager and I have made a requirement for a new bed or a more appropriate hoist to be provided to enable the staff to transfer the resident safely. The garden was well maintained and the home has plans to resurface the surrounding tarmac paths this year. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including examining staffs’ records. The home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who live in the home.. All staff receive relevant training and residents say that staff are very skilled and are consistently able to meet their needs. Residents can be confident that their interests are safeguarded by thorough staff recruitment procedures. EVIDENCE: At the time of the inspection, the home was fully occupied and there were no staff vacancies. The staff rotas showed that there were five staff on in the morning, three in the evening and three staff on duty at night. There is also an assistant manager on each shift. Two residents were receiving additional support through personal carers who were supernumerary to the rota. In addition, there are cleaning and catering staff, a maintenance person and an administrator, and the home also has volunteers who support the residents with activities. The residents I spoke to, said the staff were very competent to care fro them and they were very satisfied with the staffing levels in the home. 95 of care staff have attained National Vocational Qualification level 2 and I was informed that the assistant managers had achieved the NVQ level 4 Registered Manager Award. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 20 All staff undergo a written induction when they start working at the home, and all trainees are registered on a TOPPS certified training programme. I examined the records of five new staff, which showed that proper recruitment procedures had been carried out, including obtaining references and Criminal Records Bureau checks. As part of the induction, staff were trained on mandatory health and safety subjects, such as food hygiene and manual handling. In addition, I saw certificates of attendance for courses on mental health and management of incontinence. Several staff told me they were currently attending training on the administration of medicines. A resident wrote: “ The staff are well trained and do all they can to help us. They are available 24 hours a day” Each staff file contained a job description, person specification and a contract and all employees were health screened. Formal staff supervision takes place regularly, and staff meetings are held monthly, both of which staff said they found were valuable supports in their work. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including discussions with the manager and examining documents. The registered manager has the qualifications and experience and is highly competent to run the home efficiently. Residents can be sure that the home is run in their best interests and that their financial interests are safeguarded. Generally, the health, safety and welfare of people who live in the home are protected. EVIDENCE: Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 22 The registered manager has been in post for approximately four years. She has attained the Registered Managers Award at NVQ level 4, and a Diploma in Dementia Care. I discussed the home’s AQAA document with the manager and pointed out areas where the information could be improved. All the residents and staff who I spoke to, said the manager was very approachable and was competent at running the home. The manager is supported by a deputy, two assistant managers and an administrator. There was a relaxed and friendly atmosphere in the home during the inspection with a lot of interaction between the residents and staff. Visitors were also coming and going during the day. The home’s business and financial plan for this year was available for inspection and a quality assurance audit had been carried out this year to seek residents’ and other stakeholders’ views about the service. This was in the process of being summarised, but the feedback from service users was very positive. Residents’ meetings are held monthly where they are able to express their views about how the home is run. The home’s quality assurance system has been accredited by the “Investors in People” award. The majority of the residents manage their own personal finances, but the home manages some personal money on behalf of some residents. I sampled one person’s records at random and found them to be in order. Records and important documents were well structured and easily accessible. I saw certificates of safety relating to gas, fire and electric installations. Portable electrical appliances had been tested, and the home had a current employer’s liability insurance certificate. The fire log showed that the fire alarms were tested weekly and that fire drills took place. Accidents and incidents were properly recorded. Staff records showed that the staff had been trained in health and safety. Following the last inspection, the water temperature is regularly monitored to prevent the risk of scalding. However, it is over a year since the water storage tanks had been tested for Legionella, and I have made a requirement for this to be done. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 23 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 Requirement The Statement of Purpose must be updated to include all the information required in Schedule 1 of the National Minimum Standards. This should state the criteria for admission to the “Care unit”, and that couples can be accommodated in the home. An accurate record of all medication that is administered must be maintained. This requirement is amended and restated from the last inspection. The previous timescale was 30/06/06. A new bed or a more appropriate hoist must be provided to enable the staff to transfer a specific resident safely. The water storage tanks in the home must be tested to confirm that Legionella bacteria is not present in the system. Timescale for action 28/02/08 2. OP9 13(2) 31/01/08 3. OP22 16(2)(c) 31/01/08 4. OP38 13(4) 28/02/08 Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations The manager should seek advice from the G.P and/or the pharmacist about the appropriate time for residents to receive their medication. This will minimise the risk of errors in administration of medicines. Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 3rd Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sunridge Court DS0000010526.V343769.R01.S.doc Version 5.2 Page 27 - 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. 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