Inspection on 05/05/10 for Sandringham Road

This is the latest available inspection report for this service, carried out on 5th May 2010.

CQC found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandringham Road 21/06/07

Sandringham Road 04/03/06

Sandringham Road 12/11/05

Sandringham Road 03/03/05

Sandringham Road 22/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Random inspection report Care homes for adults (18-65 years) Name: Address: Sandringham Road 263 Sandringham Road Intake Doncaster DN2 5JG three star excellent service The quality rating for this care home is: The rating was made on: 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. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Jayne White Date: 0 5 0 5 2 0 1 0 Information about the care home Name of care home: Address: Sandringham Road 263 Sandringham Road Intake Doncaster DN2 5JG 01302739894 01302739894 Caroline.lovell@rdash.nhs.uk www.syha.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Caroline Jane Lovell Type of registration: Number of places registered: Conditions of registration: Category(ies) : South Yorkshire Housing Association care home 6 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Conditions of registration: Date of last inspection Brief description of the care home 6 6 Sandringham Road provides accommodation and personal care for six people with learning disabilities. The accommodation is a purpose built bungalow with the space, facilities and equipment to accommodate people with physical disabilities including people who use wheelchairs. The accommodation is located at the edge of Intake/Wheatley Hills area of Doncaster. This suburb of Doncaster is about four miles from the town centre and there are local facilities such as shops, library and a health centre close by. The home has an adapted Care Homes for Adults (18-65 years) Page 2 of 12 Brief description of the care home minibus enabling access to the wider community. All people attend a range of day care provision that includes social education during Monday to Friday. Annual holidays, regular outings and social events are provided for everyone. The service is provided through a partnership between South Yorkshire Housing Association and Doncaster Healthcare Trust. South Yorkshire Housing Association own and operate the service with Doncaster Healthcare Trust providing the staff. All people of the living at the home have a licence agreement with South Yorkshire Housing Association. This partnership provides and operates three other such residential schemes in the Doncaster area. The statement of purpose and the service user guide are available on request and contain information about the services available at the home. The homes past published inspection reports are also available on request. A range of information that may be useful to people using the service or their relatives and representatives was displayed on the homes notice board. For information about current fees and any additional charges please contact the home. Care Homes for Adults (18-65 years) Page 3 of 12 What we found: This was an unannounced random inspection, to comply with our regulatory processes of the inspection of services. The visit started at 09.45 and finished at 13.45. A random inspection means we visit the service and look at specific areas. On this inspection it was about the health, safety and wellbeing of people who use the service. The excellent star rating for this service was made at the previous inspection visit on 21 June 2007. We can only change the star rating following a key inspection, therefore, the rating for this service will stay the same following this random inspection. However, we can still inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. We completed Annual Service Reviews (ASR) for the service on 20 June 2008 and 8 July 2009. We only do an ASR for services rated as excellent or good that have not had a key inspection in the last year. An ASR is part of our regulatory activity and is an assessment of our current knowledge of a service rather than an inspection. The published ASR is a result of that assessment. Our judgement for both of the ASRs was that the home continued to offer excellent outcomes for people using the service. Before we visited the service we looked at any information we had received since the services last inspection. This included: The services AQAA (Annual Quality Assurance Assessment). The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. The outcomes from the previous inspection report. We also looked at what the service had told us about things that have happened at the service that have affected peoples health, safety and welfare. These are called notifications and are a legal requirement. We also sent out surveys to people living at the service, their representatives (this could either be a relative or an advocate acting on their behalf), health professionals and staff. Information on surveys returned from people using the service completed by their representatives, told us the people were unable to understand the questions we were asking them. However, three were returned from the peoples representatives about their assessment of the quality of the service, three from health professionals and three from members of staff. During the visit, time was spent looking round the bungalow and talking to people using the service, a relative, an advocate, members of staff and the manager. We observed some care practices and looked at some records and documents. The outcome was as follows: Information in the AQAA completed by the manager indicated that people have the Care Homes for Adults (18-65 years) Page 4 of 12 complaints and safeguarding information available in an easy read format in the service user information file. We saw that information about how to complain was also displayed on the notice board in the home. This is better, because people living there and their representatives can see it easily rather than having to go and seek the information in the service user information file if they needed to use it. The AQAA told us one complaint had been received in the last twelve months that had been resolved within 28 days. We looked at the complaints record to check the complaint had been investigated and action taken if necessary. There was no record of the complaint. The manager said this was because it had been sent to the trust to deal with and was held centrally. When we spoke to a relative and advocate of a person using the service, they told us they would be confident raising any issues with the manager or staff. They all said care staff and managers always treated people well and they felt they were safe and well protected. Two of the surveys returned by representatives stated they knew how to make a complaint, one couldnt remember. They all stated the service responded appropriately if they had raised any concerns. Two of the surveys returned from health and social care professionals stated the service have always responded appropriately if they have raised any concerns, one stated they were unable to comment. Two of the staff surveys told us they knew what to do if someone raised concerns about the home, one didnt answer. When we spoke to one member of staff during the visit they told us they knew what action to take if anyone raised concerns about the service. The AQAA and inspection of our records told us there had been no safeguarding allegations made. This means concerns about keeping people safe from harm. The service had the South Yorkshire Safeguarding of Vulnerable Adults in place to refer to if they needed. Information from the staff training matrix and discussions with staff, told us all staff received training on Safeguarding of Vulnerable Adults from abuse. We spoke to a member of staff in detail about their understanding of protecting people from harm and abuse. They understood very well what to look out for to identify if someone could be at harm of abuse and they knew the right action to take to help people keep safe. After a recent inspection at a service also managed by the same manager, they were now aware of the need to report any allegations of harm and abuse to the adult safeguarding authority in accordance with the South Yorkshire policies and procedures. When we spoke to the member of staff they stated they had received training on the Mental Capacity Act and Deprivation of Liberty Safeguards. We saw this when we looked at their training records. However, this was some time ago and it is suggested that all staff attend current training on the subject. This is to make sure they are up to date with current practice to ensure peoples choices and human rights are only affected following assessments, best interest meetings, risk assessments and discussion with the person concerned and/or their advocate. Care Homes for Adults (18-65 years) Page 5 of 12 We looked at the systems in place for dealing with medicines, to make sure that people were sufficiently protected by them. This was because CQC had been sent two notifiable incidents about medication errors that had happened at the service. We became aware of more medication errors during the visit that hadnt been reported. The manager stated this was due to their understanding of what was a reportable incident and this had been rectified as a result of a visit by CQC, to another service in the group. Some people took medication with them when they left the home, because it may be needed. There was no system in place to verify what the medication was, the dosage, descriptions for its use and when it was returned. This meant there was not an accurate record of medication available at the service or for people to whom the responsibility of administering the medication was transfered. In addition, we were unable to check the record of stock held for that particular medication, because a nurse was not in charge and carers did not have access to all cupboards. However, it must be noted, staff had sufficient stock to administer the medication to people if necessary. Medication that remained in stock from one month to the next was not carried forward on individual medication administration records. A stock book was used for this purpose. This meant one record did not give all the information about medication for an individual. Discussions with the member of staff also told us there was one particular type of medication that could only be administered by staff in charge who had received appropriate training. If a member of staff was not available who could administer the medication, it meant the person would be sent to accident and emergency. This meant consistent action was not in place to meet peoples needs. The above also highlighted that there was not always sufficient staff on duty to meet peoples needs in a timely manner, not only because of the administration of medicines, but also because of the needs of people who lived at the home. For example, on the day of the visit three staff were on duty. Two left the building to bring one of the people living at the service back from day care. This left one member of staff in charge with four people. For those people one needed close monitoring because of identified needs that had been expressed during the morning, another because they needed help with drinking and at the same time another person came and indicated assistance was needed for them to meet their needs. That particular person had received no individual quality contact from staff during the morning. When we spoke to a member of staff they told us they had received medication training and a competency assessment was completed every three months to determine their competence to continue with this aspect of their role. We did not verify this information as the manager was not available during all of the inspection. We saw that peoples allergies were recorded on their individual medication administration record (MAR), to reduce the risk of people being given the wrong medication. When we spoke to a member of staff it highlighted that medication received into the home can only be signed in by a nurse. This meant there could be a delay in people getting their medication. Information on one MAR didnt correspond to the persons individual care plan, which meant they could be placed at risk from receiving the wrong dose of medication. The Care Homes for Adults (18-65 years) Page 6 of 12 manager was told she must update this immediately. Comments from representatives about what the service do well included, we find all services given are done to a high standard and in a cheerful manner, all staff are very helpful and friendly. All residents are happy and well cared for and residents are always clean and presentable, the home always clean and overall the standard of care is good. One representive commented in what they could do better, we feel for people who dont have regular family visits it would be helpful for residents to have an advocate visiting, to get to know the person. Comments from health and social care professionals about what the service did well included, support individuals with complex health needs to enjoy all aspects of life. They give excellent care and provide a lovely welcoming home for service users to enjoy and be proud of, staff within the home are extremely caring towards the individuals and have excellent relationships, individualised care, I would be happy for a relative of mine to live at Sandringham Road and homely atmosphere. Appropriate risk managements used e.g. manual handling. Good provision of specialist equipment. Staff appear skilled at working with complex individuals and act respectfully towards them whenever I have visited. About what the service could do better health and social care professionals stated, with additional resources they would be able to offer more individual outings and current transport is not really suitable for service users and can limit their social opportunities. Sometimes communication has not been good, but this appears to be improving. May have been due to teething problems due to new manager. Comments from staff about what the service do well included, the residents are always turned out well i.e. well dressed, clean and all their personal needs met. They have a varied menu, with all named products bought. There is always fresh fruit and vegetables provided. Visitors are always made welcome and feel comfortable here and look after the service users needs. About what the service could do better, staff commented, if they had a vehicle that could take more residents out at any one time and get out on more trips would be better for the residents wellbeing, have more staff and a bigger bus to take service users out more on day trips and holidays and we could do with more staff on a Tuesday and Thursday morning so we do not have to rush to get service users ready for day care. What the care home does well: What they could do better: They must put in place systems to record the type, dosage and details of the administration of medication that is taken by people from and received back into the home, so that an accurate record of medication is maintained at all times and the risk of people receiving the wrong dosage of medication is minimised. Care Homes for Adults (18-65 years) Page 7 of 12 Record the carried forward medication from one month to another on each individual medication administration record, so that there is only one record of the stock held for the person. In addition, put a system in place where medication stock can be checked by appropriate authorities, so that it can be verified people are being given their medication correctly. Have on shift at all times a suitably trained member of staff, able to receive medication into the home and administer all medication to people, so that peoples wellbeing is promoted and their health maintained. Review staffing levels, so that peoples needs are appropriately met, including their medication. They must keep a record of all complaints that have been made so, that it can be verified that they have been investigated to make sure peoples views are listened to and acted on. Arrange current training for all staff on the Mental Capacity Act and Deprivation of Liberty Safeguards, so that all staff are up to date with current information on the procedures to follow to ensure peoples choices and human rights are maintained. This is because limitations on personal choices and rights must only be made following assessments, best interest meetings, risk assessments and discussion with the person concerned and/or their advocate. Report all notifiable incidents to CQC, so that proper procedures are followed and monitored to make sure the incidents have been investigated to minimise further occurrences, so that the health, safety and welfare of people are protected. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 8 of 12 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 9 of 12 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 A suitably trained member of staff must be on duty at all times to administer medication to people. So that peoples wellbeing is promoted and their health maintained. 07/08/2010 2 20 13 There must be a record of the type, dosage and details of the administration of medication that is taken by people from and received back into the home. So that an accurate record of medication is maintained at all times and the risk of people receiving the wrong dosage of medication is minimised. 07/06/2010 3 22 17 There must be a record at 07/06/2010 the service of all complaints that have been made and the action taken in respect of that complaint. So that it can be verified that they have been investigated Care Homes for Adults (18-65 years) Page 10 of 12 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action to make sure peoples views are listened to and acted on. 4 33 18 Staffing levels must be reviewed. So that peoples needs are appropriately met, including being given their medication at the identified times. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 07/08/2010 1 20 The medication administration record should have the amount of medication carried forward medication from one month to another on the record, so that there is only one record of the stock held for the person. A system should be put in place where medication stock can be checked by appropriate authorities, so that it can be verified people are being given their medication correctly. All notifiable incidents should be reported to CQC, so that proper procedures are followed to make sure the incidents have been investigated to minimise further occurrences, so that the health, safety and welfare of people are protected. Current training should be arranged for all staff on the Mental Capacity Act and Deprivation of Liberty Safeguards, so that all staff are up to date with current information on the procedures to follow to ensure peoples choices and human rights are maintained. This is because limitations on personal choices and rights must only be made following assessments, best interest meetings, risk assessments and discussion with the person concerned and/or their advocate. 2 20 3 22 4 23 Care Homes for Adults (18-65 years) Page 11 of 12 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 12 of 12 - 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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