Inspection on 13/09/05 for Sancroft Hall

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13/02/07

Sancroft Hall 21/02/06

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 Ms Sue Barker Unannounced Inspection 13th September 2005 10:30 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 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 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 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/1/05 Brief Description of the Service: Sancroft Hall is a residential care home providing personal care and accommodation for 50 older people. It is owned and run by Freemantle Trust. 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 Care Manager has responsibility for the Home and two attached day centres. The Home is purpose built with residential areas on two floors. The Home consists of five separate units, called Houses, for ten service users 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. Service users have spacious single rooms and all include en-suite toilet and wash hand basins. Each House has living and dining areas. There is a large, private garden at the rear of the Home accessible from the units on the ground floor. Units on the 1st floor have balconies leading off the living rooms. Communal facilities include a hairdressing area and a shop/trolley shop service. There are parking spaces to the front of the building for visitors. The local optician, dentist, chiropodist and district nursing service come in to the home to provide a service for residents. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on a warm September day from mid morning to late afternoon. A translator, Ms Nirvala Dohdia, assisted the Inspector during the unannounced inspection of 2 of the houses in the care home. The inspector toured the premises and spoke to a number of residents in some of the Houses, as well as greeting and speaking with members of staff on duty, including the Manager. Residents kindly let the Inspector know about what it was like to live in Sancroft Hall. There were various visitors to the care home during the unannounced inspection. 12 of the Key National Minimum Standards were assessed at this unannounced inspection with the remainder to be inspected at the second statutory inspection during the inspection year. The unannounced inspection covered standards relating to the assessments of potential residents, resident’s care plans, health care, resident’s social contacts and activities, community contact, meals and meal times, complaints, premises, hygiene and infection control What the service does well: What has improved since the last inspection? Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 6 Staff review resident’s care plans on a monthly basis in order to update their care needs. 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. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 New residents are assessed prior to admission and have care plans in place. EVIDENCE: A sample of resident’s care plans were viewed in 2 of the care home’s 5 houses. There was a care plan for each resident. The Inspector discussed the process whereby residents are referred to the care home with Ms Courtenay. The Group Care Co-ordinator carries out the assessment of potential residents and care plans are developed ideally before a resident moves in. Ms Courtenay indicated that the care home’s assessment would involve the resident and their families/representatives. When the local authority refers potential residents, the Inspector reaffirmed that it is appropriate for the Manager to obtain a summary of their single Care Management (health and social services) assessment. This should be part of the assessment process in order that the care home can decide whether it can meet the potential residents’ care needs or not. Ms Courtenay spoke of examples when it had not been possible to offer a placement to a potential resident as it was felt that the care home could not meet their needs. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 9 Two residents kindly commented that they were spending short periods of respite in Sancroft Hall. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 &9 All the residents have personalised care plans, which reflect their care needs and how these are to be met. There was evidence that residents had contributed to the content of their care plans. They have regular access to all health care professionals that come into the home. The home’s medication policy ensures that resident’s medication needs are met. EVIDENCE: The Inspector viewed a sample of 4 resident’s care plans from 2 houses. They included essential information about the resident and their personal life summary. There were statements of the resident’s like and dislikes. The resident and their key worker from within the staff team had signed this. The care plans were detailed and covered aspects of the service users’ daily living activities, relationships and values and health. A night care plan was also in place for each resident, which detailed his or her personal nighttime routines and preferences, with preferred make-up of the bed. There was a care plan summary in place as well as risk assessments for moving and handling, nutrition and pressure sores and those areas specific to the resident. There was written evidence of care plans having been reviewed monthly. Staff identify where changes have been made in the care plan. Ms Courtenay stated Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 11 that a full review of the care plans is held annually. This is recorded as occurring. Evidence gained during the unannounced inspection indicated that ranges of health care professionals visit the care home including chiropodist, dentist and district nurses. A number of residents confirmed that their GP visits them in the care home. Staff also call for an ambulance when a resident is unwell. There is a record of the resident’s GP in their individual files. Residents confirmed that staff provide them with assistance with personal care tasks as needed and requested. This information is included within individual’s care plans. Some residents stated that exercise sessions are held in the care home. Residents were observed walking around the building. Individual files indicated that staff monitor resident’s weight on a monthly basis. The Inspector discussed with Ms Courtney the need to maintain and retain a record of individual resident’s nutritional intake that had not recently been happening. This is required. The medication systems in one House were viewed. Its contracted pharmacist supplies a pre-filled blister pack system of medication administration to the care home. The medication cupboard was locked but it clearly was not large enough to accommodate the needs of the resident group. Ms Courtney indicated that it was to be replaced. Some residents confirmed that staff give them their medication. The daily medication administration records for the house were viewed. There were a number of staff signatures missing and in addition there is a need for consistency when in recording when residents are administered medication on an as required basis. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Residents’ interests are recorded and it was confirmed that they are offered the opportunity to participate in activities or interests of their choice. Residents receive visitors. Residents are offered a varied diet in Sancroft Hall. EVIDENCE: Residents kindly confirmed that a range of choices are available to them in Sancroft Hall in terms of leisure, food, cultural pursuits, religious observance and daily routines. Staff record residents’ individual wishes within these areas in their care plans. Some residents spoke of a room in their House that was their shrine. The Interpreter and Inspector were kindly invited by residents to view this room. Residents stated that religious festivals were celebrated in Sancroft Hall. Information was displayed in the care home regarding forthcoming social events. Residents confirmed that they attended the adjacent day centre, which was seen as a positive aspect of the services available to them in Sancroft Hall. The member of staff within of the houses advised residents that she would play games with residents during the afternoon if time permitted. Residents in another House were playing a softball game. Residents in one House stated that they had been offered the opportunity to go on a day trip but they had not wished to. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 13 Residents confirmed that they received visitors to the home, though staff preferred the visits to not occur at lunchtime. Residents confirmed that the food served to them in Sancroft Hall was of a good quality and that 2 choices were available for their lunch of the day. In addition snacks and drinks were available at other times. The lunch of the day was viewed in one house. This consisted of a pork casserole or fish in parsley sauce with mixed vegetables and boiled potatoes. This was followed by a choice of fruit crumble with cream or fresh fruit. The meal was served with a cold drink. Residents confirmed that a diabetic diet was available in Sancroft Hall. The menu for the day was displayed in different community languages within each lounge viewed. Residents confirmed that they could eat their meals in the dining areas or their bedrooms. There are 2 separate vegetarian and meat kitchens in Sancroft Hall. The minutes of a recent Residential Committee Meeting were displayed in each house. Issues around food and activities had been discussed. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The residents are protected by the home’s complaints policies. EVIDENCE: The Inspector viewed a copy of the ‘Feedback’ policy that had been produced by The Freemantle Trust. This invites ‘complaints, compliments or questions’ about the service. It includes reference to the Commission for Social Care Inspection with contact details for the Harrow office. The policy presented as comprehensive though it did not include an assurance that (in the case of complaints) that the complainant will be responded to within a maximum of 28 days. This is required. Staff maintain a record of complaints and compliments received in Sancroft Hall, with satisfactory detail of investigation, actions taken and outcomes. There had been 11 complaint recorded in the 12 months prior to the unannounced inspection. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Residents live in mostly a comfortable, clean and homely environment within Sancroft Hall. Residents have personalised some of the communal areas of the care home. Resident’s accommodation is mostly clean and well-maintained. Residents’ laundry is washed within the care home’s laundry facility. The laundry presented as well organised. EVIDENCE: The Inspector viewed the communal areas of the building with the Manager and members of staff. Sancroft Hall has a large well-maintained garden to the rear. It offers level access to residents. Some residents were sitting outside on the afternoon of the unannounced inspection. Some residents spoke positively about the care home’s garden facilities. During the unannounced inspection a number of maintenance and cleanliness issues were noted that are included in the list of requirements to be met below. There had been a recent Environmental Health Officer visit to Sancroft Hall and Ms Courtney spoke the home’s work in meeting the recommendations. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 16 Residents spoke positively about the quality of the accommodation available in Sancroft Hall that is always kept clean by staff. The home has a large laundry that presented as well organised. Its location does not necessitate the carrying of laundry through areas where food is stored, prepared, cooked or eaten. The laundry floor finish presented as being of an impermeable nature. The laundry contains commercial 3 washers and 2 driers. Residents confirmed that their clean laundry is returned to their bedrooms by staff. Dedicated laundry staff are employed in Sancroft Hall. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The residents are cared for by what is largely a stable staff group. There are a significant number of care hours vacant and cover for these vacant hours are provided by staff working extra hours and agency workers. There were no indications that the staff team employed in Sancroft Hall was not meeting the needs of residents. EVIDENCE: The Inspector viewed staff rotas in respect of caring (night and day), domestic and catering staff. There were 9 care staff on duty when the Inspector arrived to carry out the unannounced inspection. Care staff were observed on duty in each of the Houses. The Inspector met with both domestic and catering staff who were on duty at the time of the unannounced inspection. Ms Courtney advised the Inspector of the steps that had been taken to recruit to vacant posts within the care home. The Inspector spoke to a number of staff who had worked there since the care home opened. Residents praised the quality and caring skills of the care staff employed in Sancroft Hall. It was also stated that at times the care staff were very busy. Staff were observed interacting in a positive and caring manner with all the residents. Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 20 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 2 Standard OP8 OP9 Regulation 17 13 Requirement A record of individual resident’s nutritional intake must be maintained and retained. A full record must be maintained of when medication is administered to service users by staff. There must be consistency when staff record when residents are administered medication on an as required basis (PRN). The ‘Feedback’ policy did not include an assurance (in the case of complaints) that the complainant will be advised of the action (if any) that is to be taken within a maximum of 28 days. This is required. Plan for the redecoration of the communal areas of the building that are showing evidence of damage and wear, with completion by 13/1/06 Arrange for replacement of communal carpeting in the building, particularly those areas that are showing signs of wear or staining. Arrange for the kitchenette DS0000017559.V250427.R01.S.doc Timescale for action 23/10/05 23/10/05 3 OP9 13 23/10/05 4 OP16 23 13/01/06 5 OP19 23 13/01/06 6 OP19 15 13/01/06 7 OP19 23 13/11/05 Page 21 Sancroft Hall Version 5.0 8 OP26 23 flooring seals to be re-sealed where lifting or missing in order to ensure that they are impervious. Ensure that those areas of the kitchenette floors that are difficult to clean (for example next to fridges) are included in the cleaning schedules for the care home. The Statement of Purpose must be amended to include clarification about nursing care and emergency /respite provision, fire safety policy, the complaints section needs to be expanded to include timescales and that service users can contact the CSCI, information about the review process used in the home, number and room sizes and that the home is inspected by the CSCI and availability of the inspection reports. A copy of this document must be sent to the Commission for Social Care Inspection (Previous timescales of 30.9.04 and 31.3.05 not met) This was not viewed during the unannounced inspection. 13/10/05 9 OP1 4 13/12/05 10 OP35 12 The service users finances policy must be updated to state that staff are precluded from making or benefiting from service users wills. The whistle blowing policy must be updated to refer to the CSCI. (Previous timescales of 30.9.04 and 31.3.05 not met) This was not viewed during the unannounced inspection. 13/12/05 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 22 11 OP29 7 The recruitment and volunteers policies require updating to include information that CRB checks are required prior to working in the home. Previous timescales of 30.9.04 and 31.3.05 not met) This was not viewed during the unannounced inspection. 13/12/05 12 OP31 12 The job description for the manager is required to be amended to include that the appointed manager will be subject to registration under the Care Standards Act 2000 and that reference is made to their accountability to the National Minimum Standards for Older People (Previous timescales of 16.9.05 not met). This was not viewed during the unannounced inspection. 13/12/05 13 OP38 37 The accident reporting procedure must be updated and linked with the procedure for the reporting of Regulation 37 accidents/ incidents/ deaths etc to the Commission for Social Care Inspection. (Previous timescales of 30.9.04 and 31.3.05 not met) This was not viewed during the unannounced inspection. 13/12/05 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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 Sancroft Hall DS0000017559.V250427.R01.S.doc Version 5.0 Page 25 - 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. 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