Inspection on 21/02/06 for Sancroft Hall

This inspection was carried out on 21st February 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sancroft Hall 12/01/09

Sancroft Hall 13/02/07

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 Dia Balraj Unannounced Inspection 21st February 2006 09:00 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.V270916.R01.S.doc Version 5.1 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.V270916.R01.S.doc Version 5.1 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 admin@fremantletrust.org Manager.winglodge@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 Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 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.V270916.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection started in the morning and lasted to the late afternoon. A translator, Ms Bina Gandhi, 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 all of the Houses, as well as speaking with members of staff on duty, including the Manager. Residents were welcoming and responded to questions about various aspects of care in Sancroft Hall. The inspector met with the manager and checked progress regarding requirements of the last inspection. The inspection focussed additionally on the remaining Key National Minimum Standards which had not been assessed during the last inspection. What the service does well: What has improved since the last inspection? The registered person had complied with a number of requirements from the last inspection. The redecoration of the communal areas of the building, a Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 6 record of nutritional intake for all residents and medication records had been completed. 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.V270916.R01.S.doc Version 5.1 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.V270916.R01.S.doc Version 5.1 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): This standard was not inspected. EVIDENCE: Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10, 11(8, 9 last inspection’s requirements) Residents are treated with sensitivity and their privacy is upheld. The death policy ensures the respect and sensitivity to be accorded to residents and their family. Health care needs are met but delay in accessing services of a chiropodist. EVIDENCE: The inspector spent time in all units and was able to speak to residents and to observe the interaction between staff and residents. All residents interviewed stated that their privacy and dignity were respected. Staff were observed to knock and to wait for an answer prior to entering bedrooms. The inspector noted that residents were asked what clothes they wanted to wear. The inspector observed that residents were spoken to with respect. Some residents have keys to their bedrooms and lockable bedside cabinets. The home has a death policy, which outlines the procedure to be followed in the case of death. This takes into account the religious and cultural needs of residents. The care plans inspected stated residents’ individual wishes. The requirements of the last inspection relating to standards 8 and 9 had been implemented. The home now had a record of the nutritional intake of each resident and the records of medication were in order. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 10 There was evidence from examination of individual care plans that residents’ health and personal care needs were met. 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. A resident stated that she had sore toenails due to the delay experienced in accessing the services of a chiropodist. This was discussed with the manager who agreed to liaise with the Chiropody services. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15 Residents’ interests and choices are recorded and it was confirmed that they are helped to exercise choice and control over their lives. Residents are offered a nutritious and varied diet but choices of one resident not always met. EVIDENCE: Residents 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. Residents’ individual wishes within these areas are documented in their care plans. Some residents spoke of a room in their House where they practiced religious observances. 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. It was noted that residents could choose the time they get up and have breakfast. Some residents were observed to be having breakfast at 11:00 and staff asked and gave residents their choice of breakfast. A resident was having cups of tea as per her choice. The individual units had staff on site to prepare cooked breakfast according to residents’ wishes. Residents were engaged in Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 12 various activities. Some were meeting other residents from another unit, others were playing a softball game. Residents spoke of the adjacent day centre, which was seen as a positive aspect of the services available to them in Sancroft Hall. Residents from the Asian unit stated that they had been taken out to the temple and cultural events. There are 2 separate vegetarian and meat kitchens in Sancroft Hall. 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 vegetarian meal as chosen by residents. It included “ chapattis, rice, dhal and two cooked vegetables and salad and a rice pudding. 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. A resident in one house told the inspector that she wanted more variety especially at night when she would prefer not to have sandwiches. This was discussed with the member of staff on duty. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home’s policies, the training of staff ensure that residents are protected from abuse. EVIDENCE: Residents stated that they were treated with respect and staff were very caring. The written policy on abuse specifies that residents must be protected from all forms of abuse. Staff interviewed were aware of the abuse policy and stated that the topic was covered in induction. Staff are required to sign a copy the abuse policy as part of their annual review. Ten members of staff have followed POVA training. It is required that POVA training is undertaken by all members of staff. 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. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and26(last inspection’s requirements) The home provided a well maintained environment. EVIDENCE: The registered person had complied with the requirement of the redecoration of the communal areas of the building. The manager stated that the replacement of communal carpeting would be completed by the end of March. The home had a good standard of hygiene and was well maintained. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 15 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): 28,29 Residents are cared for adequately by staff. The home’s recruitment policy safeguards residents. EVIDENCE: The inspection confirmed that there were a number of qualified and experienced staff. 20 members of staff had completed the NVQ level 2. The Deputy manager had a NVQ level 3. The training profile of staff confirmed that they had undertaken mandatory training such as moving and handling, food hygiene, medication, health and safety. The requirement for staff to undertake POVA training is identified in standard 18. The care manager stated that all staff had had CRB checks. Two written references are also obtained prior to appointing a member of staff. Two staff’s files confirmed that appropriate checks were carried out. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 16 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): 31,32,35,38 The management of the home ensures the welfare of residents.. Financial records of residents’ personal allowances are available but were not detailed.. The health and safety of residents are protected. EVIDENCE: The registered manager has been managing the home since November 1999 and possesses the Registered manager’s award. She has also undertaken periodic training to update her knowledge whilst managing the home. Supervision takes place monthly. The manager supervises the deputy and 3 group care coordinators. The deputy supervises 3 senior night staff. The three group coordinators supervise the day care staff and the senior night staff supervises the night carers. The home deals with a part of the personal allowances of 30 residents. Records are kept on the computer but the item on which the expense was incurred was not always recorded. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 17 There were risk assessments on all residents. The home had policies on Infection control and other health and safety issues. Staff had undertaken moving and handling training, food hygiene. Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 X X 3 Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 16(2) i Requirement Timescale for action 21/05/06 2. OP8 13 The registered person must ensure that residents’ individual choices in terms of meals are reviewed on a regular basis so as to meet residents’ choices. The registered person must 21/05/06 ensure that the services of a chiropodist are readily available residents who require this service. The ‘Feedback’ policy did not 21/05/06 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. Arrange for replacement of 21/05/06 communal carpeting in the building, particularly those areas that are showing signs of wear or staining. The registered person must ensure that POVA training is undertaken by all members of staff. 21/05/06 3 OP16 23 4. OP19 15 5. OP18 4 Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 20 6. OP18OP35 12 11. OP29 7 12. OP31 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 31.3.05 and 13.12.05 not met) This was not viewed during the unannounced inspection. 13/12/05(previous timescale) 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(previous timescale) 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 13/12/05 not met). This was not viewed during the unannounced inspection. 21/05/06 21/05/06 21/05/06 Sancroft Hall DS0000017559.V270916.R01.S.doc Version 5.1 Page 21 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.V270916.R01.S.doc Version 5.1 Page 22 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.V270916.R01.S.doc Version 5.1 Page 23 - 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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