Inspection on 09/01/08 for Sambrook Care Limited

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Good service.

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

Sambrook Care Limited 14/11/06

Sambrook Care Limited 02/03/06

Sambrook Care Limited 16/08/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sambrook Care Limited Sambrook House Sambrook Nr Newport Shropshire TF10 8AL Lead Inspector Martin George Key Unannounced Inspection 9th January 2008 09:45 X10015.doc Version 1.40 Page 1 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 Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 2 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery 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. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sambrook Care Limited Address Sambrook House Sambrook Nr Newport Shropshire TF10 8AL 01952 550210 01952 550690 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sambrook Care Ltd Mrs Gillian Burroughs Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: Sambrook House is situated in the small village of Sambrook, in the vicinity of Newport in Shropshire. The home is registered to provide accommodation and personal care for twenty-eight older people. The home has been converted from a large country house and there are double and single rooms, some of which have en-suite toilet facilities. The accommodation is on two floors, the upper being accessed by stairs or via a lift. On the ground floor are pleasant lounges and dining areas, which are well decorated and comfortably furnished. The well-maintained grounds are suitable for service users to wander and relax. Care planning is done in consultation with service users where possible and plans are reviewed regularly. The home offers a variety of in-house activities, which are optional. Outings and special events are arranged throughout the year. The home makes their services known to prospective service users in the Statement of Purpose, Service User Guide and web site, which also contains the contact e-mail address for the home. The inspection report is mentioned in the statement of purpose and summarised in the service user guide. It is also on display in the entrance hall. Fees are reviewed annually and are kept competitive. The few additional charges made by the home are clearly laid out in the terms and conditions. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out by a single inspector between 09:45 and 17:00. As part of the inspection all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’ were inspected. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home through their annual quality assurance assessment (AQAA). The views of a number of people living and working at the home were acquired through discussions during the inspection. Information was analysed prior to inspection and helped to formulate a plan for the visit and helped in determining a judgement about the quality of care the home provides. On the day of the inspection we spoke to the owner, registered manager, staff and service users and observed practice and this provided evidence in support of the records that were also checked on the day. What the service does well: What has improved since the last inspection? The home now has a walk-in shower room, providing an additional option for service users. Medication procedures have been updated to make them more robust and minimise the risk of medication errors being made. The home has appointed a manager who has identified areas for development and is actively driving change forward. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 6 What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Pre-placement assessments of need are carried out to ensure that service user needs are identified and met and are reviewed to keep them up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user records we looked at provided evidence of pre-placement assessments of need. These included areas detailed in National Minimum Standard (NMS) 3.3. A significant percentage of service users are self-funding, with assessments carried out by the manager, or in her absence one of the seniors, who are qualified to carry out this role. For service users funded by the local authority the necessary assessment was completed prior to admission. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 9 The Annual Quality Assurance Assessment (AQAA) submitted by the home explains that pre-placement visits by prospective service users and their families is actively encouraged and also confirms that a contract is issued to service users if they express a wish to remain at Sambrook House beyond the first month. Within the first month they are provided with a detailed welcome pack and told about the main functions of the home. The manager informed us that the home does not provide intermediate care, but will agree to brief respite care if the home has a vacancy. Should this occur a full needs assessment will take place. Although the AQAA states that emergency placements are allowed the manager informed us on the day that she has not taken any emergency admissions and was not expecting to. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The medication procedure has been updated to improve the safeguarding of service users from potential medication errors. Overall practice within the home is respectful and sensitive to service user needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We found evidence of assessment of the personal, health and social care needs of service users in the records we looked at. Discussion with the manager identified that she wishes to improve how the information about service users is collected and recorded and also identified that she feels the information needs to be more comprehensive. The manager also wants to incorporate information pertinent to the Mental Capacity Act, which she is acquiring knowledge about through training. Any improvements arising from staff having more comprehensive information would benefit service users. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 11 The home has had some medication errors in recent months, openly and quickly reported as required by regulations. The home has subsequently reviewed and updated the procedures relating to medication. We observed part of the lunchtime medication run, carried out by one of the seniors. The process used to administer the medication was consistent with good practice guidelines. We also asked the senior to show us how the ordering, storage, administration, recording and disposal of all medication (including controlled drugs) is managed. The senior also explained how the home manages the medication for service users who self-medicate. We were satisfied that the home has an efficient medication policy, designed to safeguard service users from medication errors and the senior given primary responsibility for this area of practice evidenced good knowledge and competence. Shortfalls identified in an audit undertaken by a representative from the Primary Care Trust in May 2007 have been acted on and all medication is now stored in suitably locked cupboards. Because this is a key safeguarding area of practice we would like to see the home explore the possibility of sharing primary responsibility for medication between the two seniors, with the manager clarifying responsibility and accountability, and her part in that. She should also maintain a vigilant oversight to ensure procedures are consistently put into practice, so ensuring that service users are fully safeguarded at all times. The manager informed me that all staff able to administer medication will have to complete a competency checklist sheet. The home is to be commended on the way it responds to identified shortcomings. Observations throughout the day of the visit, discussion with the manager, owner and staff and comments made to us by service users evidenced that respect, sensitivity and dignity are integral to the culture of the home. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. Service users are engaged and stimulated through a range of activities, especially during the Wednesday activities day. Service users enjoy meals that are varied and nutritious in pleasing and relaxed surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspection took place on a Wednesday, which is designated as an activity focussed day at the home. In the morning, during a tour of the premises, we observed an arts and crafts activity. Service users involved in the activity were engaging well and told us they were enjoying the activity. In the afternoon we observed a sing-a-long session and many of the service users were singing along to the pianist and appeared to be enjoying themselves. Some service users entered the local village produce show and won several awards, showing how the home helps to maintain links with the local community. Staff informed us that there were occasions when it was more difficult to engage service users in activities because of demands on staff time, resulting from having to assist in non care duties, such as helping in the kitchen. To counter this though we Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 13 were impressed by the efforts made by staff to meet service user needs as well as possible, despite the demands on their time. The home is very accommodating to visiting professionals and relatives, evidencing their willingness to be scrutinised. The home also recognises the importance of allowing service users to meet their visitors in private should they so wish. The home listens to, and tries hard to meet, the expressed needs and preferences of service users wherever possible. The quality, variety and nutritional value of the food provided is of a good standard and where possible is locally sourced. Observation at lunchtime evidenced that service users enjoyed the food and dined in pleasing surroundings. The AQAA identifies that an area of improvement in the past 12 months has been additional help in the kitchen, but this help should not be provided by taking care and domestic staff away from their primary duties. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The well being and protection of service users is given the necessary priority and staff are trained to a good standard in this area of practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a good complaints procedure on display on the notice board in the entrance hall. This is also given to service users on admission. There have been no complaints lodged in the past year so it is difficult to judge how effectively the home would use the procedure and how satisfactory any resolution would be. However, the homes’ willingness to be open to scrutiny is an indicator that they would be responsive to an individual making a complaint and would aim to reach a resolution that was in the interests of the service user group and overall development of the home and work practices. All staff have attended protection of vulnerable adults (POVA) training and observation of practice on the day and discussion with staff satisfied us that knowledge, awareness and competence in this area of practice is sufficient to satisfactorily safeguard service users from the risk of all forms of abuse, including financial. The home has procedures that explain how to deal with a suspicion or incidence of abuse. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users benefit from the commitment of the home to maintain and improve their living environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is very well maintained throughout, giving service users a comfortable living environment that is pleasingly decorated and furnished, taking their needs and preferences into account. Bedrooms we visited were personalised to suit the preferences of the service user. Improvements to the environment in the past year have included the installation of a walk in shower room, renewal of most of the carpeting in communal areas and redecoration of the entrance hall. The home was also Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 16 successful with a grant application to allow for the renewal of communal furniture. The benefit of these improvements for the service users is self evident. During a tour of the premises the owner told us that bedrooms are decorated following a discharge and prior to a new admission. The current manager has significantly improved working practices to help reduce the risk of cross contamination and so minimise or eliminate potential harm to service users. She told us she has reinforced the importance of staff wearing protective aprons and gloves. A new contract for improved hand washing facilities throughout the home and the purchase of better quality cleaning materials are other examples of how health and safety issues have been addressed. The home has a cleaner on duty every day to ensure all areas of the home are kept clean and hygienic but the importance of their health and safety function is somewhat negated when they are called away from their cleaning duties to help in the kitchen. The laundry has good quality washing and drying machines suitable for the number of service users. The locked, metal Care of Substances Hazardous to Health (COSHH) cupboard is situated in the laundry area. The home responds well to comments made by regulating authorities, such as the fire service and environmental health. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Recruitment practices and the commitment to training and qualifications shows how the home wants to provide high quality care to service users. To ensure service user needs are met at all times the home should review current staff roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The range of skills, knowledge and experience in the staff team is good and is being further enhanced through a comprehensive training programme. The manager prioritised the need for training following her appointment, as she found some of the training to be out of date. She is utilising external trainers. The commitment to ongoing development and qualification, especially NVQ, is commendable. We checked staff records and found them to be compliant with schedule 2, Care Homes Regulations. All necessary checks were found and the files contained evidence of good recruitment and induction processes, the latter ensuring staff are provided with a level of competence necessary to provide safe care for service users. To reduce the risk of records getting misplaced the Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 18 home may wish to adopt a more secure filing method than the one currently being used. The care staffing complement is sufficient to meet the needs of the service user group under normal operating circumstances but this is adversely affected by the need for care staff to regularly help in the kitchen, due to there being no kitchen assistant. During these periods the numbers of staff having direct interaction with service users is reduced, leading to an increased risk of some needs not being met and the potential for service users to be more susceptible to harm, due to reduced supervision. All staff spoken to expressed concern about these temporary staffing difficulties and one staff member also highlighted how hard it then was to respond to unplanned circumstances. Fortunately there is a commitment from staff to cover in times of need, but this places additional demands on them. Discussion with the manager and owner assured us that they are fully aware of this issue and have considered several strategies for managing it effectively, but the current arrangement does not fully meet the complex needs of service users, some of whom have developed dementia. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. Service users are benefiting from a competent staff team who want to provide the best possible care and a management team that are open to scrutiny and committed to continuing development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager holds both the Registered Manager Award (RMA) and NVQ level 4 and has significant experience in the adult care sector as a practitioner and Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 20 manager. During discussion with us she provided evidence of a good knowledge base and a desire to integrate up to date legislation and guidance into the policies and practices of the home, ensuring service users are consistently provided with a competent staff team who can meet their complex needs. Lines of accountability are generally understood but it would be beneficial to reinforce who staff need to refer care related matters to in the manager’s absence. Since her appointment the manager has identified areas for improvement and has addressed some and is working toward resolving outstanding priority areas. One of these is staffing levels, which at some key times of the day are presenting a potential health and safety and safeguarding issue, due to care and/or domestic staff occasionally being redirected from their primary role to assist in the kitchen. This practice needs to be reviewed to ensure the hygiene related health and safety needs of service users are maintained by not redirecting domestic staff from their key role and the risk of cross contamination is eliminated by having dedicated kitchen staff. Discussion with the manager and owner about this issue assured us that there is ongoing consideration about how best to meet all the staffing requirements across the whole spectrum whilst continuously meeting service user needs and protecting them from harm. We are also satisfied that the necessary degree of importance is being given to resolving this matter. The financial interests of service users are well protected by the home. There is a good system for safely managing their personal money and the Resident’s Comfort Fund is separately managed by two members of staff and a service user and all these systems are readily made open to scrutiny by the home, as required. There have been some staff changes in recent months and this, combined with the change of culture and improvements in the recording systems being led by the manager, necessitates good quality and consistent support to both new and established staff. To ensure the changes in staff, culture and systems are successfully integrated the manager should make sure formal supervision consistently meets or exceeds requirements, helping staff understand and feel confident in implementing changes that will benefit service users. The home shows a commitment to continually developing the service it offers to the people it cares for. The manager, owner and staff we spoke to are fully aware of the need for good health and safety practices and respond appropriately to recommendations from regulatory authorities, such as environmental health and the fire service. All staff have undertaken training in infection control. Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 4 3 x 3 Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP27 Good Practice Recommendations The home needs to review the practice of redirecting care and domestic staff from their primary role to help out in the kitchen in times of particular need to ensure the risk of cross contamination is consistently and effectively managed Formal supervision for care staff needs to occur at least six times per year to ensure staff are given the appropriate levels of direction and support 2 OP36 Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Sambrook Care Limited DS0000063772.V352637.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!