Inspection on 14/06/05 for 25 The Sandfield

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Other inspections for this house

25 The Sandfield 07/02/07

25 The Sandfield 10/01/06

25 The Sandfield 30/03/05

25 The Sandfield 02/11/04

25 The Sandfield 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 25 The Sandfield Northway Tewkesbury Glos GL20 8RU Lead Inspector Simon Massey Announced 14 June 2005 11:00 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 25 The Sandfield Address Northway Tewkesbury Glos GL20 8RU 01684 - 275894 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) H5M057Humphries@mencap.org.uk Royal Mencap Society Lynne Humphries(To be registered) Care Home - Personal Care 4 Category(ies) of Learning Disability (4) registration, with number of places 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30/03/05 Brief Description of the Service: 25, The Sandfield is a detached property on a larger housing estate approximately two miles form the centre of Tewksbury. The home is close to local amenities and facilities. The home provides care and support to four adults with Learning Disabilities. The home is owned and maintained by New Era Housing Association and staffed and run by the Royal Mencap Society. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours and the inspector interviewed staff and met two of the service users. Records and documentation were examined and also the environment. What the service does well: What has improved since the last inspection? What they could do better: The home needs to enjoy a period without management changes to ensure consistency for staff and service users. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1&5 The home has a Statement of Purpose and Service User Guide that accurately reflect the services that are provided. EVIDENCE: Amendments to the information required in the documents have been made to reflect the changes in the home. Copies of these must be supplied to the Commission. There have been no admissions to the home during the previous twelve months. All personal files contain details of tenancy agreements and placement contracts. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,&9 The home has a care planning system in place that meets the needs of the service users. This is currently being further improved by the introduction of a person centred approach to the developing of plans and their subsequent reviews. EVIDENCE: The inspector saw a sample of the new format for care planning that the new manager is introducing. The new system will ensure that plans are based upon the wishes of the service users. The goals and objectives are clearly identified and then reviewed every 3 to 6 months. The plans contain life histories, written in the first person, assessment of abilities and skills and details of the amount and type of support that is required. They also contain a “pre-review” service user questionnaire that is to be completed. People are supported to make decisions and there was evidence of staff providing guidance and information to service users to encourage them to broaden their range of activities. The personal files contain risk assessments that have been reviewed and updated when required. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,16&17 The home supports the service users to develop individual lifestyles that meet their needs by encouraging choice and providing opportunities for the development of skills. EVIDENCE: The service users all have reasonably settled weekly routines but an effort has been made recently to encourage people to consider some different options in terms of trips out and day care activities. The manager and staff said that some progress has been made, with a few increased trips at weekends occurring. Consideration is being given to whether one service user, who has for some period now declined to attend the day-centre, can be supported to access some other form of day care. Service users appear happy with their routines and the inspector observed, as on previous visits, that this is generally a relaxed and happy house. Staff encourage service users to be involved in the domestic routines within the house, according to their abilities, and the staff and manager stated that 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 11 recent efforts to encourage people to take more responsibility were having positive results. The home enjoys a good relationship with the surrounding community and makes use of local amenities and facilities. The home was well stocked with fresh and packaged produce at the time of the inspection and the menus showed that variety and choice were provided. Input and advice on diets is provided to all the service users. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19&19 The home meets the health and personal care needs of the service users and has systems in place for the monitoring of care and recording of information. EVIDENCE: The personal files detail the care and support that is required and the appropiate sections in the personal files showed that appointments are made and supported. The home supports one person who has diabetes and a new information package for staff is being provided that aims to increase their knowledge and understanding of this area. All staff have been trained by the district nurses on the procedure for the administering of insulin. Subsequent to the inspection the inspector has supplied the manager with some additional guidelines about the procedures required for the provision of certain clinical procedures within care homes. The homes medication and administration system was examined and found to be in order. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22&23 The home has a complaints procedure with evidence that service users can express their views to staff and management. EVIDENCE: No complaints have been made to the Commission during the previous twelve months. The manager has contacted the Community Learning Disabilities to arrange for some input from the Speech Therapist. Increasing the communication skills of the staff team will further help the staff to respond to any concerns raised by service users. Staff have attended the Mencap “Protect Me” course, which focuses on adult Protection issues. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29&30 The home provides a comfortable and homely environment that is clean and hygienic throughout. EVIDENCE: The home is well maintained and decorated throughout. The bedrooms are personalised and service users are fully involved in the choosing of décor and new furniture and fittings. New carpets were being fitted in the bedrooms at the time of the inspection. The entire environment was inspected and records were seen of maintenance that had been completed. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35&36 The home has an experienced and established staff team that are motivated towards meeting the needs of the service users. EVIDENCE: The home has an established staff team that are responding positively to having a new permanent manager. Staff are able to demonstrate a good understanding of the homes aims and philosophy and have respectful and positive relationships with the service users. All staff are now receiving monthly supervision. The team have received input from the district nurses on the subject of diabetes as well as the required training for the administering of insulin. The recording system has been simplified to avoid unnecessary duplication in recording which has resulted in information being easier to access. Staff interviewed were positive about the recent changes to the administrative processes and commented that this helped the staff team be more consistent Three staff are currently completing NVQ 3 training and all staff are up to date with the required statutory training. The home has regular staff meetings and staff stated that they are able to contribute and that their ideas and input are listened to and acted upon. Staff were positive about the support they have received from the manager. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 16 There has been a decrease in the amount of agency staff being used, with only four shifts being covered during the previous month to the inspection. The agency staff that have been used are all familiar with the home and the service users. The recruitment procedures were not examined as part of this inspection. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,41&42 The experienced and qualified manager is providing direction and leadership to the staff team. EVIDENCE: The home has a new manager who will be submitting an application to be registered. They are currently the registered manager of another Mencap home, where they have worked for several years. The manager has the experience and qualifications required for the position, and is providing leadership and direction for the staff team Supervision is taking place and there have been regular staff meetings. The manager has also implemented the planning of an updating and improvement to the care planning system. Much information has now been archived making the files easier to use and material easy to access. The requirement for regulation 26 visits to be completed is being met by the homes service manager, who has monthly supervision sessions with the manager. Copies of these reports are being supplied to the Commission. All safety checks have been completed and correctly recorded. 25 The Sandfield D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 2 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 25 The Sandfield Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 3 3 x D51_D03_S16327_25TheSandfield_V212537_140605_Stage4_A.doc Version 1.30 Page 19 no Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The home must supply copies of the updated Statement of Purpose and Service User Guide to the Commission The home must register its manager Timescale for action 31/08/05 2. 37 8 31/08/05 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. 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