Inspection on 12/01/09 for Sancroft Hall

This inspection was carried out on 12th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sancroft Hall 13/02/07

Sancroft Hall 21/02/06

Sancroft Hall 13/09/05

Sancroft Hall 19/01/05

Sancroft Hall 05/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Sancroft Hall Sancroft Road Harrow Middlesex HA3 7NS     The quality rating for this care home is:   three star excellent service 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 assessment of the service. We call this a ‘key’ inspection. Lead inspector: Tony Lawrence     Date: 1 4 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Sancroft Hall Sancroft Road Harrow Middlesex HA3 7NS 02088619930 02088619963 Manager.sancroft@fremantletrust.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ann Courtney Type of registration: Number of places registered: The Fremantle Trust care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: 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 Date of last inspection Brief description of the care home Sancroft Hall is a care home for up to 50 older people. It is owned and run by Freemantle Trust, and 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 manager of the home has responsibility for the home and two attached day centres. The home consists of five separate units, called houses, for ten residents each. Two of these houses are Care Homes for Older People Page 4 of 30 Over 65 0 50 50 0 Brief description of the care home 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. At the time of inspection the fees for the service were: Private residents - £553 per week Residents funded via social services - approximately £440.20 per week, dependent on the residents individual contribution. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection took place on three separate days from Monday 12th - Wednesday 14th January 2009. During these visits we assessed outcomes for people living in the home against the National Minimum Standards for care homes for older people. We did this by spending time talking with residents, their relatives, staff and managers in the home. We also checked care records kept by staff, toured the building and saw all communal areas and some residents bedrooms. On Tuesday 13th January we carried out a 2-hour SOFI observation in the lounge of a unit for Asian elders with dementia. SOFI helps us assess and understand whether people who use services are receiving good quality care that meets their individual needs. It allows us to get an insight into the general well-being of individuals and staff Care Homes for Older People Page 6 of 30 interaction with people who use the service during the observation. We use the information from this methodology to triangulate evidence to help us to make judgements about how well services are meeting peoples individual needs. The homes Manager returned the Annual Quality Assurance Assessment (AQAA) we sent to her. The completed AQAA included excellent information about the home and the people who live and work there. 12 staff and 2 residents also returned confidential surveys we sent to them as part of this inspection. We have used their comments to inform judgements we have made in this report. What the care home does well: What has improved since the last inspection? What they could do better: 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 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides excellent information for potential residents in languages and formats they can understand. People who move into the home know that their care needs will be assessed before they move in. Evidence: I was able to visit before I moved in and my daughter also visited. Comment from a resident. We had enough useful information about the home before moving in. Comment from a relative. We always have enough information about the care needs of people we look after. Comment from a member of staff. Care Homes for Older People Page 10 of 30 Evidence: We have encouraged families to prepare bedrooms for new service users in advance of admission. This helps people to feel at home as soon as they arrive. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we saw that the home provided new residents with an information pack that included a copy of the Statement of Purpose and Service User Guide to the home. The Statement of Purpose was reviewed and updated in September 2008. The Service User Guide was updated in July 2008. We saw that both documents provided excellent information for people who may be considering moving into the home. The information pack also included a series of excellent fact sheets to help people make the decision to move into a care home. The homes Manager told us that the information pack could be produced in Gujarati and other languages or formats, if required. During this visit we reviewed the way five people were referred and moved into the home. Residents and their relatives we spoke to told us that the home had given them clear information about the home before they moved in. Residents also told us that they, or their relatives, had visited the home before making the decision to move in. We saw that staff from the home had visited each person before they moved in to complete the providers own care needs assessment form. The Deputy Manager told us that this was used to develop an initial care plan, together with information provided by the social services department and healthcare professionals. The assessments we saw were well completed and provided good baseline information about each persons care needs and how they would be met in the home. The Manager confirmed that the home did not provide intermediate care and Standard 6 did not apply. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and healthcare needs are well recorded and people have access to the healthcare services they need. People get the medication they need and staff keep accurate records of all medication. Managers and staff need to make sure that people staying for periods of respite care have the same quality of care planning and risk management as people living in the home permanently. Evidence: The staff are very good and will arrange for me to see the doctor whenever I need. Comment from a resident. I spend a lot of time in my room. The staff are very good, they always knock when they want to come in. Comment from a resident. Each service user has a support plan which details action to be taken that supports their care needs. Each plan has risk assessments that are developed to enable residents to achieve a good quality of life and minimise risks of daily living. Extract Care Homes for Older People Page 12 of 30 Evidence: from the providers Annual Quality Assurance Assessment (AQAA). During this visit we reviewed the care plans for five people living in the home. Four people were permanent residents and the fifth person stayed for regular periods of respite care. We found that the home had very good care plans for people who lived in the home permanently. Their care plans covered their personal and health care needs and how these would be met by staff working in the home. We saw that the care plans for the four permanent residents had been regularly reviewed and all had been reviewed and updated during 2008. The plans included clear and achievable goals to make sure that people maintained their independence as much as possible. We also saw that each of the care plan files included risk assessments for manual handling, pressure care, nutrition, fire safety and other potential risks. The risk assessments had been well completed and included guidance for staff on how identified risks should be minimised. We saw good evidence that residents, their relatives and/or representatives had been involved in agreeing their care plan and risk management strategies. We saw that peoples care plans included a good record of all healthcare appointments. These records were evidence that people had access to the primary healthcare and remedial services they needed. Following this inspection, the home needed to improve the care planning and risk management for people who stay in the home for periods of respite care. The care plan that we saw had been written in March 2006 and reviewed in December 2006. We saw no evidence that the care plan had been reviewed or updated in the last 2 years, although the person had stayed in the home for regular periods of respite care. We also saw that none of the providers risk assessments had been completed for this person. Managers and staff in the home must make sure that people who stay for periods of respite care receive the same standards of care planning and risk management as people living in the home permanently. All five people whose care we reviewed during this visit had a separate night care plan that detailed peoples routines and preferences at night. We saw that these night care plans had been regularly reviewed. During this visit we checked the way that staff in the home managed residents prescribed medication. We found that medication was well managed and safely stored. Records showed that each person got the medication they needed at the right time and staff made sure that accurate records were kept. Each house had its own secure storage cabinets for residents prescribed medication and these were kept well organised by staff. There was a need for staff in one house to make sure that the Care Homes for Older People Page 13 of 30 Evidence: opening date was recorded on bottles of residents eye drops. This would make sure that this medication was disposed of within the advised time scales. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff support residents to maintain their hobbies and interests and stay in contact with relatives and friends. Most people enjoy the food that is provided but more work may be needed to maintain standards when agency cooks are employed. Evidence: I enjoy the food, theres always a choice and theres plenty of it. Im always being asked if I want a cup of tea! Comment from a resident. The quality of food varies when there is an agency cook. What is needed is someone to keep an eye on the kitchen when food is being cooked by agency cooks, especially at weekends. Comment from a resident. You wont get better food on the High Street! Comment from a resident. It would be good if people had more stimulation. Comment from a relative. Our service provides the highest standard of care and support for residents, regardless of their gender, race or faith. And its delivered by a professional, caring Care Homes for Older People Page 15 of 30 Evidence: and understanding team, 24 hours a day. Comment from a member of staff. We look after the residents well, we know their needs and help them to try and celebrate all events. Comment from a member of staff. We meet the religious and social needs of our service users by hosting religious services from different groups and visiting lay people. Some people go out regularly to church services. Many people prefer to use their own private facilities within the home to celebrate their faith. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we spent time talking to residents, managers and staff and checking care plans and daily reports completed by staff working in each of the 5 houses. Two of the houses provided accommodation and care for Asian elders, some of whom had dementia. We found that the care needs of Asian people living in the home were very well met. Residents had access to Asian TV channels and radio stations, a separate room was provided for prayers, staff working in the two houses spoke Gujarati and other Asian languages, menus were written in Gujarati and the home had a separate kitchen and cook who prepared Asian vegetarian meals. Each of the two houses also had a wheelchair accessible shower room to enable people personal care needs to be met in a culturally appropriate way. We saw that peoples care plans included an assessment of their social, cultural and religious needs and details of how these would be met in the home. We saw evidence that staff delivered a programme of activities that included a weekly coffee morning, board games, a quiz, ball games and life story work with individual residents. The care plans we saw for people living permanently in the home also included a leisure assessment that briefly outlined each persons hobbies and interests. This assessment had not been completed for the person staying for a period of respite care. We also saw that arrangements had been made in each of the houses for people to practise their religion. We saw that daily care notes completed by staff referred to people taking part in prayer times and visits to local places of worship. We found that the daily care notes did not reflect the work done by staff to meet peoples social care needs, focusing on personal and health care needs. Staff should record more information about activities and visitors and peoples reactions to these as part of the daily care notes, to show peoples social care needs are met. All of the care plans we saw included information about peoples relatives, friends and other significant people. Daily care notes also included some references to visitors. Some residents told us that their relatives managed their finances for them and staff Care Homes for Older People Page 16 of 30 Evidence: from the home made sure that they had money to spend on personal items from the homes own shop or local shops. We checked the residents finance records with the homes Administrator and saw that a good record was kept of income and expenditure for each person. People living in the home could be confident that their money would be safely managed and they would have access to their own money when necessary. We saw that daily menus were available in each of the houses and these were provided in Gujarati in the two houses for Asian elders. The menus showed that a variety of nutritious meals were provided and choices were available at each meal time. We watched staff serving lunch on two days of this inspection and the food was well presented, with plentiful portions. Most residents ate their meals in the dining rooms in each house, but arrangements had also been made for some people to eat in their rooms if they preferred. Most of the residents we spoke with during this visit told us that they enjoyed the meals provided. Other people told us that the quality of food varied, especially when agency cooks had to be used. We discussed this with the homes Manager who explained that she had introduced a daily feedback form for residents to complete to enable her to monitor catering standards. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Residents and others involved with the home say they are happy with the services provided and feel safe. Evidence: Ive never needed to make a complaint, but Im sure the staff would deal with it if I did. Comment from a resident. Id talk to any of the staff or the Manager if I needed to talk about any concerns. Comment from a relative. If I was worried about any of the people living here, Id talk to the Manager. Comment from a member of staff. The Freemantle Trust has in place a complaints procedure which is called Freemantle Feedback which complies with the National Minimum Standards. The Manager takes complaints very seriously and investigates each case with great care and attention and does so promptly. Extract from the providers Annual Quality Assurance Assessment (AQAA). Information from the providers Annual Quality Assurance Assessment (AQAA) was Care Homes for Older People Page 18 of 30 Evidence: evidence that the home had received 7 formal complaints during 2008. We saw that each complaint was well recorded on the providers Feedback form, with clear information about actions taken by staff from the home and other agencies and the outcomes for the person making the complaint. The Feedback forms had also been used to record the compliments and thank you cards received from residents relatives. The Manager told us in the AQAA that the Feedback form was available in a language appropriate to ours service users origins. We saw that the home had a copy of the local authoritys Safeguarding Adults policy and procedures for staff reference. Information from the providers AQAA was evidence that there had been no safeguarding adults investigations or referrals during 2008. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in an environment that is appropriate to their specific needs. The home is a pleasant, safe place to live and all bedrooms are single, with en suite facilities. People are supported to personalise their rooms and communal areas provide a choice of areas to meet relatives and friends. Evidence: My room is lovely, Ive got all my things with me. Comment from a resident. I spend a lot of time in my room and the staff let me keep it how I like it. Comment from a resident. We never lock the doors - all residents should be able to go anywhere they want. Its our job to make sure that we know where people are and that they are safe. Comment from a member of staff. Property management forms are in place and monitored by the Manager. Certificates are held to ensure health and safety compliance. All documents are checked during the annual quality audit. Extract from the providers Annual Quality Assurance Assessment (AQAA). Care Homes for Older People Page 20 of 30 Evidence: Sancroft Hall was purpose built as a care home in 1999 to provide care and accommodation for 50 older people, in 5 units each designed for 10 people. Each unit (known to residents and staff as houses) has 10 single rooms, each with en suite toilet and wash hand basin, communal lounges, bath and shower rooms. Two houses are on the ground floor and a large passenger lift gives residents access to three houses on the first floor. The home has a large garden for residents use and car parking for visitors. During this visit we saw all communal parts of the home and some residents bedrooms with their permission. We saw that lounges were well decorated and comfortably furnished. The Manager told us that fireplaces, with coal effect gas fires had been fitted in each lounge, following requests from residents. carpets in all communal parts of the home had been replaced, following a requirement we made after our last inspection. The residents bedrooms that we saw were spacious, well decorated and comfortably furnished. Residents told us that they could bring their own furniture with them and that they especially appreciated the en suite facilities provided in each room. While most of the bedroom furniture we saw was of good quality, some individual items needed replacement and the provider should provide suitable replacements, where needed. During this visit, all parts of the home that we saw were clean, pleasant and hygienic. We also saw that there were no physical restrictions in any part of the home, including the two houses for people with dementia. Doors were open throughout the home and residents were able to walk freely around all parts of the home and garden. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and others have confidence in staff working in the home. Rotas show that the home is staffed efficiently, with particular attention given to busy times of the day and the changing needs of residents. Evidence: The staff are very good, they do everything to help me. Comment from a resident. All the staff work very hard. Usually there are enough people around, but sometimes you have to wait a while for someone to help. Comment from a resident. The staff are very good, its a hard job and they do all they can for the people living here. Comment from a relative. The service does almost everything well but there is always room for improvement. Employing good, hard working staff and holding them on to them is very important for the service we provide. Comment from a member of staff. There is good team work and communication between seniors and other staff. Comment from a member of staff. Care Homes for Older People Page 22 of 30 Evidence: The home has in place a staffing rota that has been designed to support the assessed needs of people living at Sancroft Hall. The staffing ratio is in line with Department of Health guidelines. The home has in place a training matrix which is up to date and reflects the quality of training provided to staff. All staff receive induction training and understand that they must attend mandatory training as well as necessary training to develop their individual skills. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we saw that there were sufficient staff at all times to meet the identified care needs of people living in the home. Staffing ratios varied in the five houses, with more staff available to support people with dementia. During the three days we spent in the home we saw that staff worked well together in all five houses to respond promptly and appropriately to residents requests for support. We also saw a handover between morning and afternoon staff where the senior on duty described significant events during the previous shift that affected each resident. People living in the home can be confident that there will be sufficient staff on duty at all times to meet their care needs. Information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) showed that the training needs of staff working in the home were discussed and appropriate training was provided. During this visit we checked the personnel files for three staff working in the home. These showed that all the required pre-employment checks, including written references and Criminal Records Bureau (CRB) checks, were completed before new staff started work in the home. People living in the home could be confident that only staff who are suitable to work with older people are employed in the home. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager communicates a clear sense of direction, is able to evidence a sound understanding and application of best practice and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the Manager. The AQAA contains excellent information, supported by appropriate evidence. People live in a home that is well managed and they and their representatives are fully involved in maintaining and further improving excellent standards of care. Evidence: We have a good manager, she is always available to support staff and she really cares about the residents. Comment from a member of staff. Weve received questionnaires asking us for our views on the way the home is run. I know they ask residents for their views as well. Comment from a relative. The manager ensures that there is an open and approachable management structure Care Homes for Older People Page 24 of 30 Evidence: that supports all staff. Sancroft Hall is culturally rich with a staff team of staff who come from different cultural backgrounds. The staff team work to the code of practice provided by the General Social Care Council. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we saw that the home had an experienced and qualified manager who we had registered as a fit person to manage a care home for older people. The manager told us that she had a social work qualification, was an NVQ Assessor and had completed the NVQ Level 4 Registered Managers Award. She also told us she had worked with older people since 1971 and had been the manager of Sancroft Hall since it opened in 1999. We found that the manager had a very good knowledge of current best practise, especially working with older people with dementia and Asian elders. Before this inspection, the Manager completed the Annual Quality Assurance Assessment (AQAA) that we sent to her. We saw that the AQAA was very well completed and it gave us excellent information about the home that we have used to inform this report. The residents, their relatives and staff we spoke to during this visit told us that they were regularly asked for their opinions on how the home was run. The Manager told us that there was an annual quality audit that included the views of residents, their relatives and staff. The quality audit was used to develop action points to improve care practices and also an annual Development Plan for the home. The Manager also told us that a meeting was held for residents every two months. We saw that the last meeting was held in December 2008. The minutes of the meeting showed that it was well attended, an interpreter was provided to enable people living in the two houses for Asian elders to take part and there was a good record of the issues discussed and actions agreed. We saw that copies of the meeting minutes were displayed on notice boards around the home for residents and visitors information. During this visit we checked the management of residents personal finances with the homes Administrator. We saw that, where people were not able to manage their own finances, this was well managed by staff and accurate records were kept. To make sure that staff were supported to maintain standards and develop their skills working with older people, there was a need to make sure that all staff received formal supervision with a senior member of staff at least 6 times a year. The Manager told us that this had not always been possible, due to senior staff shortages. During this visit we reviewed a selection of records kept by staff in the home. These included residents care plans and risk assessments, medication and finance records. All of the records we saw were well completed, up to date and regularly reviewed. Care Homes for Older People Page 25 of 30 Evidence: We saw no health and safety concerns during this inspection. Care Homes for Older People Page 26 of 30 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, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 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, Care Homes 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 7 15 Managers and staff in the home must make sure that people who stay for periods of respite care receive the same standards of care planning and risk management as people living in the home permanently. This will make sure that the care needs of people staying for respite care are met and they are cared for safely. 30/04/2009 2 36 18 The Manager must make sure that all staff receive formal supervision with a senior member of staff at least 6 times a year. This will help to make sure that staff are supported to maintain care standards in the home and develop their skills. 30/04/2009 Recommendations Care Homes for Older People Page 28 of 30 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 1 9 Staff should record the opening dates on bottles of residents eye drops to make sure that the advised disposal dates are met. Staff should record more information about activities and visitors and peoples reactions to these as part of the daily care notes, to show peoples social care needs are met. The provider should draw up a plan to make sure that residents bedroom furniture is replaced when required. 2 12 3 24 Care Homes for Older People Page 29 of 30 Helpline: 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 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. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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