Inspection on 13/02/07 for Sancroft Hall

This inspection was carried out on 13th February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sancroft Hall 12/01/09

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sancroft Hall Sancroft Road Harrow Middlesex HA3 7NS Lead Inspector Louise Phillips Key Unannounced Inspection 13th February 2007 10:20a 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 DS0000017559.V318450.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. DS0000017559.V318450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sancroft Hall Address Sancroft Road Harrow Middlesex HA3 7NS 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) 020 8861 9930 020 8861 9963 Manager.sancroft@fremantletrust.org Manager.Millhouse@fremantletrust.org The Fremantle Trust Ann Courtney Care Home 50 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (30) of places DS0000017559.V318450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: 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 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 - £515.58 per week Residents funded via social services – approximately £413 per week, dependent on residents individual contribution. These are subject to an increase in April 2007. DS0000017559.V318450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day, and was carried out by an Inspector and a Regulation Manager from the CSCI. Time was spent talking to nine staff, sixteen residents, two relatives and the manager. A Gujarati speaking interpreter was present for some of the inspection to assist the Inspector when communicating with some of the residents. A tour of the premises was carried out and care records were inspected along with other relevant paperwork. Information has also been gained from the inspection record for the home. What the service does well: What has improved since the last inspection? 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. DS0000017559.V318450.R01.S.doc Version 5.2 Page 6 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 DS0000017559.V318450.R01.S.doc Version 5.2 Page 7 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, 4, 5 and 6 Quality in this outcome area is good. Residents are assessed prior to moving to the home and individual preferences catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 6 is not applicable to this service. A number of residents were spoken to, all who have lived at the home for varying amounts of time. Each residents’ reason for choosing to live at the home was different, one saying they had chosen it under the recommendation of their doctor, another knew about the home by having attended the day centre and another said they had “…looked at other homes but preferred it here…”. One relative said that they were attracted to the home due to the combination of Asian and English residents, which they felt was important for their Asian mother. DS0000017559.V318450.R01.S.doc Version 5.2 Page 8 One resident spoke to the inspector about their move to the home, stating that the staff “…showed me around and helped me to settle in…”. The file for two residents recently admitted to the home was examined. Findings indicate that the home has a good process for assessing and admitting new residents, with appropriate referral information being sought from the social worker, psychiatrist or other care professionals as necessary. The home uses it own assessment format that provides good information about the residents social and medical history, daily routine, likes and dislikes, strengths and limitations which is then used to develop an individualised care plan. Records indicate that after six weeks of living at the home a review is held with the resident, their family, the manager and social worker to establish whether they are happy living at the home, and that the home can meet their needs. DS0000017559.V318450.R01.S.doc Version 5.2 Page 9 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 residents’ needs are well met through attention to individual needs, preferences and care planning. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said that they feel they get good care and support, one commenting that: “…they look after you well…”, another saying that “…the staff are really good…”. A number of residents discussed openly with the inspector the help they receive with personal care. Each spoke about how this is carried in an unhurried manner by the staff, at the resident’s own pace and with respect to their privacy. The care plans for each resident are in a good format, covering significant areas such as personal care, socialising and continence needs. Included along with the care plans is a record titled ‘preferred daily routine’ detailing the individual likes of the resident throughout the day. For one DS0000017559.V318450.R01.S.doc Version 5.2 Page 10 resident on an Asian elders unit this described how in the morning they prefer to have a shower then their breakfast before going to their room for prayers. A separate night care plan provides good information about individual preferences prior to their going to bed, such as the support required, how the resident likes their bed made-up and how many pillows they need to enjoy their sleep. One relative spoke about having initially being involved in their relatives care plan and that they are now only if there are significant changes to needs. The risk assessments are individualised, covering areas of risk relating to such needs as poor mobility or poor eyesight. What was positive to see was that for residents who only speak Gujarati, a risk had been identified where nonGujarati speaking staff might mis-interpret what the resident might be asking, with management plans regarding contacting nominated relatives of the resident to interpret on their behalf. The residents also spoke about being able to access the dentist, chiropodist or optician whenever they want, with one commenting that: “…I see my doctor when I need to…”. A record of all healthcare appointments is maintained in the individual care files. A pharmacy inspection by the CSCI was carried out in August 2006, and the requirements from this were follow-up during the inspection. The administering and recording of medication given by staff at the home was observed to be fine, with full initials used. However the Medication Administration Record (MAR) chart included medication that was to be given by a community nurse only. Despite an additional record indicating that this had been given, the MAR chart had not been signed by the community nurse. The service must address this to ensure the MAR chart reflects the actual medications given to each resident. There are sufficient medication policies at the home, covering areas such as correct storage of medicines, safe checking of medication prior to administration, the management of medication when a resident is away from the home and the use of ‘as required’ medication. The medicine fridge did not contain any pathology specimens and the manager stated that no such specimens are held in the fridge. DS0000017559.V318450.R01.S.doc Version 5.2 Page 11 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 good. Residents have the opportunity to be involved in activities provided by the home. Improvements need to be made to the food to ensure the preferences and cultural needs of all residents are catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: “…we have a good time here…”, “…I can go to bed and wake up as I wish…”, “…can do what I like…” and “…I don’t know where the day goes…”. These were comments from residents who said they enjoy living at Sancroft Hall. The home provides a number of activities that residents can get involved in such as bingo, card games and exercise. The inspector found that the programme displaying the activities offered was difficult to read and consideration should be given to making this clearer for residents. One relative commented that they would like to see more stimulation provided for residents with dementia. On one of the Asian elders units the resident’s described their days being filled with individual praying in their rooms, doing Bahjans (prayer chants) with DS0000017559.V318450.R01.S.doc Version 5.2 Page 12 other residents on the unit, reading together from the Holy book and celebrating all different religious festivals both at this home and at parties at other Freemantle Trust homes. Residents on these units discussed how they appreciate that a majority of the staff speak Gujarati, and that where staff do not speak this there is an arrangement with their family to interpret on their behalf. Two relatives were spoken to during the inspection, where they both said that they like being able to visit at any time and that they always feel welcomed by the staff. One relative commented that they like “…the openness of being able to turn up unannounced…”. Residents said they can phone their relatives whenever they want, and one resident was observed using a cordless phone during the inspection. The previous inspection required that more choice is provided for residents with regard to the evening meals, where a resident had commented that they did not want sandwiches. On this inspection one resident commented that they were unhappy with only being offered sandwiches in the evening and that they have to supplement this with their own food. Due to this finding the requirement is restated. On the Asian elders units the residents were very positive about the meals provided, saying that they are “…very good...” and that “…we tell them what we want and always get it…”. The food was well-presented and residents were able to eat this as they wished. The food provided on these units are vegetarian and culturally appropriate, also prepared in a separate kitchen in the home. However, one relative spoke about their mother preferring English food and they are able to get this when they want. During the inspection three afro-Caribbean residents said that the meals provided do not reflect their cultural background and that they would like these to be catered for by the service. DS0000017559.V318450.R01.S.doc Version 5.2 Page 13 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. This judgement has been made as residents feel confident to raise areas of concern they have. Improvements are needed to staff training to reduce risks to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has the Freemantle Trust ‘Feedback’ policy for addressing complaints. All the residents said that they knew who to speak to if there was something they were not happy about and that they know how to make a complaint. The staff training records indicate that some staff did POVA (Protection of Vulnerable Adults) training in July 2006, though some staff have not received an update or training since 2003. Some staff spoke about not having had any abuse/ POVA training. One staff spoken to did not know anything about POVA or whistle-blowing. The requirement for all staff to do POVA training has been restated. One carer who had completed the recent POVA training demonstrated a good awareness and understanding of abuse issues and the actions to take in the event of an allegation of this at the home. DS0000017559.V318450.R01.S.doc Version 5.2 Page 14 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. The staff and residents make the environment welcoming. The home needs to make some improvements to ensure it is more comfortable for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The environment at Sancroft Hall is welcoming, bright, spacious and homely. One resident commented that: “…its nice here, comfortable…”. Bedrooms were observed to be personalised with residents own belongings and the Asian elders units are decorated with appropriate religious and cultural symbols and artefacts. One resident said that they are aware they can bring in their own furniture, but that they choose not to. The previous inspection required that the carpets in the communal areas be replaced. The manager stated that this had not taken place and the requirement has been restated. DS0000017559.V318450.R01.S.doc Version 5.2 Page 15 Residents are positive about hygiene at the home, saying that the environment is always fresh and clean and that personal laundry is done regularly, along with the bedding. However, one resident said that they are unhappy that the cleaner comes to clean their bedroom when they are just about to eat. DS0000017559.V318450.R01.S.doc Version 5.2 Page 16 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. This judgement has been made because the service provides training so that residents receive the right level of care, although improvements are needed in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home holds recruitment information on each member of staff. The staff files contain relevant information such as proof of identification, correspondence relating to offer of job, statement of terms and conditions of employment, two references and record of the interview of staff. A record is maintained of all training done by staff, which includes training in basic food hygiene and dementia care. One carer who had worked at the home for a number of years spoke at length about the training they had done, and that they had recently achieved the NVQ level 2 in Care. The manager stated that a majority of care staff had competed the NVQ level 2, with more senior staff having completed, or are working towards NVQ level 3. During the inspection a member of staff was seen administering medication to residents, yet their training record for having received medication training was blank. In addition, training for carers in first aid is recorded as ‘N/A’ (not DS0000017559.V318450.R01.S.doc Version 5.2 Page 17 applicable) despite it being observed that they were the only staff member present on a unit on a number of occasions during the inspection. It is required that all staff receive training relevant to their role. The manager stated that there are a number of staff vacancies that are currently covered by relief and agency staff. Staff working on the Asian elder units said it can be very difficult working with agency staff who cannot speak Gujarati, as it means that they have to translate the language, which increases their workload significantly. A relative also commented that different carers is not good for their relative, particularly in area of bathing, as their relative does not like being exposed. However they did say that over the past few months there had been a more consistent team on the unit where their relative lives. DS0000017559.V318450.R01.S.doc Version 5.2 Page 18 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. There is a competent manager at the home. Developments need to be made to the supervision and support of staff, along with ensuring relevant health and safety checks are maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One relative commented that the manager is approachable, and that they “…can speak to her about any problems…”. Relatives also felt that they are kept well informed about issues concerning their relative and significant issues in the home. One relative also spoke about having attended the ‘relatives meeting’ that was in Autumn last year. Observations and discussions with the residents during the inspection were positive, indicating that the manager is respected and well-liked by the those living at the home. DS0000017559.V318450.R01.S.doc Version 5.2 Page 19 Since the last inspection improvements have been made to the ‘financial regulations policy’ to include details about staff being precluded from making or benefiting from residents wills. The records indicate that the staff do not receive appropriate supervision from their line manager. This should occur a minimum of six times a year, however records demonstrate that this occurs approximately every six to eight months. One staff commented that they thought supervision was meant to occur once a year. It is required that all staff receive a minimum of six supervision sessions a year, at regular intervals. There are records to demonstrate that health and safety checks are carried out on the fire system and equipment, fridge and freezer temperatures, lift servicing, gas safety and Portable Appliance Testing, etc. The manager stated that the electrical installation check had not been carried out since the building opened, over seven years ago. DS0000017559.V318450.R01.S.doc Version 5.2 Page 20 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 DS0000017559.V318450.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13(2) Requirement The Registered Persons must ensure that receipts of medicines administered by community nurses are recorded on the MAR chart. (Previous timescale of 01/10/06 not met) Timescale for action 30/04/07 2. OP15 16(2) (i) The Registered Persons must 30/04/07 ensure that residents’ individual choices in terms of meals are reviewed on a regular basis so as to meet residents’ choices. (Previous timescale of 21/05/06 not met) The Registered Persons must ensure that POVA training is undertaken by all members of staff. (Previous timescale of 21/05/06 not met) The Registered Persons must arrange for replacement of communal carpeting in the building, particularly those areas that are showing signs of wear or staining. (Previous timescale of DS0000017559.V318450.R01.S.doc 3. OP18 4 30/04/07 4. OP19 15 30/04/07 Version 5.2 Page 22 21/05/06 not met) 5. OP30 13(4) The Registered Persons must ensure that all staff receive training relevant to their role, including medication awareness and basic first aid. The Registered Persons must ensure that all staff receive supervision a minimum of six times a year. 31/08/07 6. OP36 18(2) 30/04/07 7. OP38 23(1)(a) The Registered Persons must 30/04/07 ensure that the electrical installation check is carried out within the timescale and that this is carried out a minimum of every five years. 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 OP12 Good Practice Recommendations The Registered Persons should give consideration to displaying the activities programme in a clearer format for residents. DS0000017559.V318450.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000017559.V318450.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!