Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Sunrise Operations of Westbourne 16-18 Poole Road, Westbourne, BH4 9DR Tel: 01202760966 Date of Inspection: 28 July 2014 Date of Publication: October 2014 We inspected the following standards as part of a routine inspection. This is what we found: Care and welfare of people who use services Requirements relating to workers Assessing and monitoring the quality of service provision Complaints Records Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 1
Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activities Sunrise Operations Westbourne Limited Mr Martin Corrigan Sunrise Operations of Westbourne can accommodate up to 112 individuals. It provides a service for older people and part of the home ("reminiscence neighbourhood") is designed specifically for people with dementia. Care home service with nursing Accommodation for persons who require nursing or personal care Diagnostic and screening procedures Treatment of disease, disorder or injury Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 6 Our judgements for each standard inspected: Care and welfare of people who use services 7 Requirements relating to workers 9 Assessing and monitoring the quality of service provision 10 Complaints 12 Records 13 About CQC Inspections 14 How we define our judgements 15 Glossary of terms we use in this report 17 Contact us 19 Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We carried out a visit on 28 July 2014, observed how people were being cared for, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We reviewed information sent to us by other authorities and took advice from our specialist advisors. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. What people told us and what we found This was an unannounced inspection which was undertaken by one inspector and a specialist advisor over the course of one day. The manager of the home, the deputy manager and members of staff assisted us throughout the inspection. The manager told us that they had applied to become the registered manager for the home and this was being processed. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? At the time of our inspection there were 104 people living at the home. We spoke with 12 people who lived at the home as well the manager and six members of staff. Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report. This is a summary of what we found: Is the service safe? People we spoke with during the inspection were generally positive about the care, treatment and support they received at Sunrise Westbourne. One person told us, "They do their best to make a difference to you." Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 4
We found that people's needs had been assessed and care plans put in place to meet their needs. The care plans were up to date and we saw were subject to regular reviews. Risk assessments had also been completed to make sure that care was delivered as safely as possible. Staff records contained all the information required by the Health and Social Care Act 2008. This meant the provider employed staff who were suitable and had the skills and experience needed to support the people living in the home. CQC is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and report on what we find. The provider sought consent from people and or their relatives in relation to their care and was reviewing procedures under the Mental Capacity Act. The manager was aware of what constituted a deprivation of liberty. They were aware of the new Supreme Court ruling and had submitted DoLS applications for people living at the home. Is the service effective? People received care and support in accordance with their care plans. Care was planned to meet people's needs. Where a need was identified, a plan was in place to meet this. For example, one person's care record stated that they required assistance to change position. This plan detailed the frequency of position changes, the equipment required and the numbers of staff. Records showed that this care was being carried out as directed. Members of staff we spoke with demonstrated to us that they understood people's care and support needs and that they knew them well. We saw various audits that showed that the quality of service to people was monitored thoroughly and people were asked their views on the service provided. Is the service caring? We found the service was caring as people were treated with dignity and respect. People generally spoke positively about the care they received. They also said that staff were kind, caring and compassionate. The following were examples of what people told us, "They do their best to make a difference to you." "The food is very good, plenty of choice." and "Very kind staff although the good ones are getting worn out." We saw that staff were kind and caring in their approach with people. Staff had information to be able to care for and support people as individuals. Is the service responsive? People's care needs were reviewed and their plans updated to ensure they received a service that met their current needs. We saw within records that actions required of staff were carried out. Action had been taken to make sure that appropriate staff were employed to meet the needs of people accommodated. People accessed the services of healthcare professionals as required. Records of visits Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 5
from healthcare professionals were kept. For example, we found that visits from chiropodists, district nurses, opticians and GPs were documented. Is the service well led? The home had systems in place for monitoring the quality of service provided to make sure that the home was run safely. Accidents and incidents were audited so that remedial action could be taken to prevent further occurrences. Other audits completed included health and safety, infection control, and medicines. People were able to comment on the service provided via questionnaires and meetings. You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 6
Our judgements for each standard inspected Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Reasons for our judgement Generally, people were positive about the care and support that was provided at the home, although there was a range of opinions expressed. The following were examples of what people told us, "They do their best to make a difference to you." "The food is very good, plenty of choice." and "Very kind staff although the good ones are getting worn out." One person told us they had had to wait on occasion longer they thought was reasonable for their call bell to be answered but the majority of people said this was not a problem for them. Members of staff we spoke with said that there were sufficient staffing levels and that call bells were answered within a reasonable time. We chose a sample of four people to case track how their care and support was managed at the home. This involved speaking to the person concerned where possible, speaking with members of staff and looking at the records maintained about the person. We found that people's needs had been assessed before they moved to the home, to make sure that these could be met at Sunrise Westbourne. This assessment was also used to determine the level of support the person would require if they were to move into the home. We saw that people's care was reviewed after six months stay at the home. On admission more in depth assessments were completed from which a care plan had been developed. The assessments covered topics such as; skin care, risk of malnutrition, their moving and handling requirements, personal care needs and assistance required to manage medication. There were also risk assessments associated with people's care plans that were in place to make sure that care was delivered as safely as possible. Examples of risk assessments included a bed rail assessment for their safe use and a falls risk assessment. We also saw that people had been involved in their care where they had capacity to make Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 7
decisions about the way they were looked after. People's care plans were up to date and people had been involved in reviews about their care. We found that people's care was planned to meet their preferences, such as being asked about the gender of carer they wished to support them. There was also information gained from people about their life histories so their spiritual and recreational needs could be catered for. The home employed an activities coordinator to provide activities and they were also supported by a volunteer to assist with one to one activities. We saw the list of planned activities for the week ahead that included outings away from the home. One person told us how they enjoyed craft activities and another told us about the trips that they had enjoyed. A member of staff told us that there were usually three outings arranged each week. We found that people's medical needs were met. Peoples' records showed that GP appointments were made when people were unwell. There was also information that evidenced people's other healthcare needs such as chiropody, dentistry and eye care were attended to. Some people had been put on monitoring charts as part of their planned care. We saw examples of food and fluid monitoring for some people and re-positioning for people who were at risk of skin ulceration. We also saw that people had been provided with equipment to meet their needs, such as air mattresses and specialist chairs. We looked at the medication administration records for the people we case tracked through the inspection and saw that medicines had been administered as prescribed by their GP. CQC is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and report on what we find. The provider sought consent from people and or their relatives in relation to their care and was reviewing procedures under the Mental Capacity Act. The manager was aware of what constituted a deprivation of liberty. They were aware of the new Supreme Court ruling and had submitted DoLS applications for people living at the home. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 8
Requirements relating to workers People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by, suitably qualified, skilled and experienced staff. Reasons for our judgement There were effective recruitment and selection processes in place and appropriate checks were undertaken before staff began work. We discussed with the manager the recruitment procedures and systems in place for the recruitment of new staff. We found that there were thorough procedures in place to ensure that suitable people were employed to work at the home. We looked at the recruitment records for a sample of four members of staff. We found that all the required checks had been completed and recorded before a new member of staff was recruited to work with people living at the home. These included: Proof of a person's identity including a recent photograph. A DBS (Disclosure and Barring Service) check, formerly known as a Criminal Records Bureau check. Satisfactory evidence of a person's conduct in previous employment where they had worked with vulnerable adults. A full employment history that accounted for gaps in employment and the reasons why a person left employment when working with vulnerable adults. Satisfactory information about any physical or mental health conditions which were relevant to the person's ability to carry out their role. The members of staff we spoke with told us that the provider gave them good training and the manager ensured that essential mandatory training was kept up to date. The manager told us that there was low use of agency staff with a full team of staff recruited. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 9
Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive Reasons for our judgement People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We found that anonymous surveys were carried out involving people who lived at the home by an external body. The last survey was carried out in March 2014; however the home was still awaiting the collated results. There were other systems in place as well for gaining feedback on the quality of service. One person told us about how each month six people would be invited to join the manager for a meal. The person told us that this, ". a good way of them getting to know you." Each month a Residents' Council, chaired by the manager was held and also provided an opportunity for people to raise concerns or to gain updates on the running of the home. A Dining Committee was also held each month and people were welcome to attend and provide feedback on menus and the food provided at the home. We were also told about the daily 'huddle' to which members of staff from each department are invited to discuss and review peoples' care. Staff we spoke with told us that they always read the care plan for a person newly admitted and that before the start of each shift there was a verbal handover to keep staff up to date with peoples' current needs. They also told us that they were provided with a handover sheet for the people they were responsible for looking after that provided core information about a person's needs. We found that there were thorough auditing systems in place to ensure there was ongoing monitoring of the service provided. The manager provided us with a summary of a comprehensive audit of the whole service that was carried out in April 2014. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 10
Each month separate audits were carried out around individual topics. We saw that other audits were carried out in February 2014 for infection control, March 2014 an audit of medication and health and safety in May 2014. Within people's records we saw accident forms completed for any accidents sustained. We found that there was a regular analysis of accidents and incidents that occurred in the home to make sure that lessons were learnt for reducing the risk of further accidents occurring in the future. Staff we spoke with told us that the home was well managed and that changes made by the new management team were improving the service provided to people living at the home. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 11
Complaints People should have their complaints listened to and acted on properly Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately. Reasons for our judgement People's complaints were fully investigated and resolved, where possible, to their satisfaction. The manager showed us a log of all complaints received about the service. We saw that all complaints were logged as well as the response to the complainant. There was evidence that complaints were taken seriously and actions had been considered to make sure that issues were addressed. People we spoke with told us that they knew how to make a complaint and people had confidence that any complaint would be taken seriously. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 12
Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Reasons for our judgement At this inspection, we found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. During our visit we looked at the care plans for four people in depth, the risk and other assessments that had been completed, daily records, monitoring charts and medication administration records. We also looked the recruitment records for four members of staff who had been employed since the last inspection in August 2013 and records relating to the quality monitoring of the service. We saw that care plans included relevant information about people's health and personal care needs and key contacts. They also showed that people's care had been assessed and planned and monitored. We saw that monitoring records for repositioning were completed in line with care plans and were reviewed daily. People who had skin injuries or pressure sores had information on the treatment and care given. There were records that detailed the progress of healing. We saw that records relating to people were appropriately stored in a secure area on each level of the building and were accessible to us during the inspection. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 13
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 14
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 15
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 16
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 17
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 18
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) 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. Inspection Report Sunrise Operations of Westbourne October 2014 www.cqc.org.uk 19