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Sunrise of Frognal Requires improvement

This care home is run by two companies: Sunrise Senior Living Limited and Sunrise UK Operations Limited. These two companies have a dual registration and are jointly responsible for the services at the home.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 July 2018

This inspection took place on 22 and 23 March 2018 and was unannounced.

Sunrise of Frognal is a ‘care home’ providing residential care for older people with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Sunrise of Frognal accommodates up to 131 people in two adapted buildings. There were 107 people using the service at the time of our inspection. This was the first inspection of Sunrise of Frognal, since their registration in August 2017, with a new provider Sunrise UK Operations Limited.

During this inspection, we found two breaches of the Health and Social Care Act 2008. The provider had not taken appropriate action to ensure that people received their medicines as prescribed in a timely way. Staff had not followed the provider’s medicines policy in relation to ordering and booking of medicines. Liquid medicines requiring opening dates had no date of opening. The medicines administration record (MAR) and medicines balance in stock reconciliation was not correct.

These shortfalls were a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Quality assurance systems were in place to monitor and improve the service. However, improvements were required as they did not identify the issues we highlighted above.

These issues were a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did see some areas of good practice with medicines. The provider had a policy and procedures which gave guidance to staff on their role in supporting people to manage their medicines safely. We saw the medicines room was found to be clean and tidy and the medicines trolley was locked at all times. We saw evidence that people's medicines were reviewed regularly by the GP.

We did see some areas of good practice with quality assurance system and processes. The service had system and process to assess and monitor the quality of the care people received. As a result of these checks and audits the service made improvements, for example, care plans and risk management plans were updated, and falls management had improved.

The service had a registered manager in post at the time of writing this report. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service sought the views of people who used the services, their relatives, and staff to improve the service. Staff felt supported by the registered manager. The service worked effectively with health and social care professionals, and commissioners.

People and their relatives told us they felt safe and that staff and the registered manager treated them well. Staff knew how to keep people safe. The service had clear procedures to support staff to recognise and respond to abuse. The registered manager and staff completed safeguarding training. Staff completed risk assessments for every person who used the service and they were up to date with detailed guidance for staff to reduce risks.

The provider carried out comprehensive background checks of staff before they started working and there were enough staff to provide support to people. The service had arrangements to deal with emergencies and staff were aware of the provider’s infection control procedures and they maintained the premises safely. The provider trained staff to support people and meet their needs. People and their relatives told us that staff were knowledgeable about their roles and that they were satisfied with the way staff looked after them. The provide

Inspection areas

Safe

Requires improvement

Updated 18 July 2018

The service was not consistently safe.

Management of medicines was not robust. The provider had not taken appropriate action to ensure that people received their medicines as prescribed in a timely way.

People and their relatives told us they felt safe and that staff and the registered manager treated them well. The service had a policy and procedure for safeguarding adults from abuse, which the registered manger and staff understood.

Staff completed risk assessments for every person who used the service and they were up to date with guidance for staff to reduce risks. The service had a system to manage accidents and incidents to reduce reoccurrence.

The service had enough staff to support people and carried out satisfactory background checks on them before they started work.

Staff were aware of the provider’s infection control procedures and they maintained the premises safely. The service had arrangements to deal with emergencies.

Effective

Good

Updated 18 July 2018

The service was effective.

People and their relatives commented positively about staff and told us they were satisfied with the way they looked after them.

Staff assessed people’s needs and completed care plans for every person, which were all up to date. Staff completed daily care records to show what support and care they provided to each person.

People and their relatives were involved in deciding their care and making day to day decisions about they want.

The service supported all staff through training, supervision and appraisal in line with the provider’s policy.

Staff assessed people’s nutritional needs and supported them to have a balanced diet.

The registered manager and staff knew the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, and acted according to this legislation.

Staff supported people to access the healthcare services they needed. The service liaised with other professionals to meet people’s needs.

Caring

Good

Updated 18 July 2018

The service was caring.

People and their relatives told us they were happy with the service. They said staff were kind and treated them with respect.

Staff involved people or their relatives in the assessment, planning and review of their care.

Staff respected people’s choices, preferences, privacy, dignity, and showed an understanding of equality and diversity.

Responsive

Good

Updated 18 July 2018

The service was responsive.

Staff recognised people’s need for stimulation and social interaction.

Staff involved people or their relatives in the assessment, planning and review of their care.

Staff prepared, reviewed, and updated care plans for every person. Care plans were person centred and reflected people’s current needs.

People had end-of-life care plans in place to ensure their preferences at the end of their lives were met.

People knew how to complain and would do so if necessary. The service had a clear policy and procedure for managing complaints.

Well-led

Requires improvement

Updated 18 July 2018

The service was not consistently well-led.

Quality assurance systems and processes to monitor and improve the service require improvement.

People and their relatives commented positively about the registered manager and staff.

The service had a positive culture, where people and staff felt the service cared about their opinions and acted on their feedback to make improvements to the service.

Information about the management of the service was shared with staff through regular meetings to ensure they understood the responsibilities of their roles.

The service worked effectively with health and social care professionals and commissioners.