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Inspection on 24/02/10 for Sancroft Hall

Also see our care home review for Sancroft Hall for more information

This is the latest available inspection report for this service, carried out on 24th February 2010.

it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Excellent.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Sancroft Hall The quality rating for this care home is: The rating was made on: three star excellent service 1 4 0 1 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Simon Smith Date of this annual service review: 1 5 0 1 2 0 1 0 Annual Service Review Page 1 of 6 Information about the service Address of service: Sancroft Road Harrow Middlesex HA3 7NS 02088619930 02088619963 Manager.sancroft@fremantletrust.org www.fremantletrust.org The Fremantle Trust Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 50 0 0 50 The maximum number of service users who can be accommodated is: 50 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Sancroft Hall is a care home for up to 50 older people. It is owned and run by the Freemantle Trust. Ealing Families Housing Association maintains the building. The home is situated off a quiet residential road near the centres of Harrow and Wealdstone with access to local transport and shops. The home consists of five separate units, called houses, for ten residents each. Two of Annual Service Review Page 2 of 6 None. 1 4 0 1 2 0 0 9 these houses are specifically for Asian elders, which now includes five beds providing specialist dementia care for that client group. Another house also provides specialist care for older people who have dementia or dementia related conditions. Some places within the home are reserved for respite care. The manager of the home has responsibility for the home and two attached day centres. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received since the last key inspection. This included: What the service has told us about things that have happened in the service. These are called notifications and are a legal requirement. Relevant information from other organisations. An Annual Quality Assurance Assessment (AQAA) completed by the provider. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. We also looked at the previous key inspection report and the results of any other visits that we have made to the service in the last 12 months. What has this told us about the service? The last inspection found that people who use the service experience excellent quality outcomes. We found that the service does the following things well: Provides excellent information for people who may want to live in the home and makes this information available in a variety of formats and languages. The care needs of people who live in the home permanently are well assessed and recorded and are regularly reviewed. The service meets the cultural and religious needs of Asian elders who live in the home. Any complaints about services provided in the home are thoroughly investigated and people who have made complaints are satisfied with the outcome. The home provides good standards of accommodation and all bedrooms have an en suite toilet and wash basin. The home has a qualified and experienced manager and a team of experienced and qualified care staff. We found that the following things had improved since the previous key inspection in February 2007: The management of residents medication, the recording of residents choices at meal times and the training of staff in safeguarding vulnerable adults. Carpets had been replaced throughout the home and an electrical safety check had been completed. We found that the service could do the following things better: The provider must make sure that people who stay in the home for periods of respite care benefit from the same high standards of care planning and risk management as people who live in the home permanently. The manager must make sure that all care staff have a minimum of six formal supervision sessions with a senior member of staff each year. We will check whether the home has improved these areas at the next key inspection. Annual Service Review Page 4 of 6 The home notified us about two medication errors in December 2009. We spoke to the manager on the telephone about this. The manager was able to demonstrate that appropriate action had been taken to improve practice and prevent reoccurrence of the errors. The AQAA told us that the home had received eight complaints in the last twelve months and that six of these had been upheld. There have been three referrals to the local authority under safeguarding vulnerable adults procedures in the last year. We found evidence that the home responds appropriately if any information comes to light that relates to potential abuse and informs all relevant agencies, including the local authority safeguarding team and police if necessary. None of the safeguarding investigations resulted in a referral to the protection of vulnerable adults (POVA) list. We asked how the home ensures that residents views are promoted. The home told us: We hold service user committee meetings eight-weekly. These are always attended by the manager. Notes of the meeting are kept and fed back to other service users. The manager walks around the home everyday and speaks to all residents to ensure that everyone has an opportunity to express their views. The shift leader also walks around the home at least once during their shift and communicates individually with each person. In addition the manager has an open door policy and encourages people to come and speak to her. The home gave the following examples of changes they had made as a result of listening to residents views: Serving dishes are now placed on tables at main meal times. Residents now meet candidates for carer posts over coffee and a chat. Residents feed back to the manager and their views are influential in selection. Members of the Residents Committee now approve the voluntary fund accounts. We asked the home whether they had experienced any barriers to improvement in the past year. The home told us that, despite considerable work put into recruitment, they had found it difficult to recruit permanent senior staff and that this had affected the support provided to care staff and placed additional responsiblilities on existing senior staff. What are we going to do as a result of this annual service review? We will do a key inspection by 13 January 2012. We may inspect the service sooner than this date if we have concerns about the quality of care or the safety of the people using the service. Annual Service Review Page 5 of 6 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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