CARE HOME ADULTS 18-65
Sandalwood 81 Almners Road Lyne Surrey KT16 0BH Lead Inspector
Marianne Barham Announced Inspection 22nd December 2005 10:20 Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 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 Sandalwood DS0000013777.V268938.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 Adults 18-65. 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. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sandalwood Address 81 Almners Road Lyne Surrey KT16 0BH 01932 568623 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) Welmede Housing Association Ltd Mr Abdool Allim Peeroo Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30-65 YEARS 27th June 2005 Date of last inspection Brief Description of the Service: Sandalwood is a large detached bungalow located in the village of Lyne in Surrey. The home is owned and managed by Welmede Housing Association and provides accommodation and care to five gentlemen who have a learning disability. All bedrooms are single occupancy and have a washbasin no rooms have ensuite facilities. Communal areas consist of a large lounge with separate dining area, a good size, homely kitchen and two bathrooms with toilets and two further toilets. There is a large, well-maintained, enclosed garden to the rear of the property and parking for several cars to the front of the building. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection carried out at 10.20am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of four hours and ten minutes and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The manager, Mr Abdool Allim Peeroo (Alan) was present and a total of three members of staff and the home’s milkman were spoken with during this inspection. The five service users were not able to give their views on the service, however they appeared to be relaxed in the company of staff members and engaged in various activities throughout this inspection. One letter and two comment cards were received from service users’ relatives prior to this inspection. These were complimentary about the care and services provided by the home. What the service does well:
The service is run as a home, with service users being involved as fully as possible in its day-to-day activities. Staff members and service users were observed to have a relaxed, friendly relationship and there is warm, homely atmosphere in the home. Great care and attention is given to ensuring that the service users’ communication needs are met and understood by the staff team. This is achieved by having clear guidelines in place for each service user. The service users are supported by the home to be a part of the local community, attending and taking part in various events and there is a full timetable of work and leisure activities in place for them to access. Members of staff spoken with said that they are happy working at the home, all had worked there for many years and demonstrated a high level of understanding and knowledge of the service users’ needs. All said they were well supported by the manager and received enough training and supervision to carry out their jobs. The milkman spoken with is on first name terms with the service users and related how some of them like to help to bring in the delivery. He stated that there is always a welcoming atmosphere in the home and feels the service users are well cared for. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 6 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. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Each service user has an individual contract with the home and the content of the agreement has been explained to them. EVIDENCE: A recommendation was made at the last inspection on 27th June 2005 that service users are made aware of the licence agreements between the home and themselves in a way in which they understand. All service users now have a copy of their individual agreement kept in the home and a member of staff explains the contents on a one to one basis. The licence agreement sets out the terms and conditions of residence in the home and also the fees charged. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Each service user has an individual plan produced with their involvement by people who know them well and they are supported to make decisions about their lives. EVIDENCE: A requirement was made at the last inspection on 27th June 2005 that care staff be trained to conduct and record care planning and risk assessments and be fully involved in the process. The manager has since carried training in this area for all care staff and it was pleasing to see evidence of their involvement in the care plans. The service users are supported to make choices and decisions in their everyday lives from when to get up and go to bed to how and with whom they spend their time. The service users in the home have little or no verbal communication and use a variety of facial expressions, gestures, body movements and vocalising to make their wishes and needs known. Each service user has communication guidelines in place for members of staff to refer to when caring for them. These guidelines are detailed and give clear instructions on the likely meaning of the non-verbal cues and of appropriate
Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 10 responses. Through the use of these guidelines and a staff team that know the service users well the home is able to ensure that the service users are able to make decisions about their lives. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 17 Service users are part of the local community and receive a nutritious, balanced diet that takes account of their individual needs and preferences. EVIDENCE: The home has strong links with the local church and village community. Service users attend and participate in local events such as the summer fete to which they contribute home made cakes. The home makes good use of the local Garden Centre and service users walk there regularly and have coffee or purchase goods as needed. The home buys all food produce locally and the service users always accompany the care staff when shopping for these items. The service users are well known in the local community and most shopkeepers are on first name terms with them. The home has four weekly menus that are put together with the involvement of the service users. These are displayed on the notice board in the kitchen and service users are also informed of the meals available on a daily basis.
Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 12 The inspector was able to observe service users having lunch and was pleased to see that they were supported in a caring and dignified manner by the care staff. The dining area is large enough for all service users and staff members to take their meals together. The service users appeared to enjoy their meal and that served to the inspector was nicely presented and tasty. The kitchen is clean and adequately equipped with a range of good quality, fresh foods that were seen to be stored appropriately. All members of staff have undertaken food hygiene training and colour coded chopping boards and other equipment was in evidence. Temperatures for the fridge, freezer and foods cooked are taken and recorded. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The home has a policy and procedure in place for dealing with medicines and all members of staff sign to show they have read and understood this. The medication records are maintained accurately with profiles in place for each service user, list of staff trained to administer medication and a list of approved homely remedies. The medication was seen to be stored securely and correctly. The home does not have any controlled drugs but has facilities and procedures in place if needed. All medication is supplied by the local pharmacy, who also carries out audits and gives advice as needed. No service users administer their own medication. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A These standards were not assessed at this inspection. Please see report dated 27th June 2005 for detail on these standards. EVIDENCE: Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The home is generally safe, clean, comfortable and homely and service users rooms are suitable for their needs, however there are shortfalls in the maintenance of the home. EVIDENCE: The home is generally well maintained, pleasantly decorated and comfortably furnished and is clean and tidy throughout. Service users’ bedrooms are suitable for their needs and the furnishings and décor reflect their individual tastes, interests and preferences. Requirements were made at the last inspection on 27th June 2005 that the air vents throughout the home be cleaned regularly and that the patio cleaner must be stored in a locked facility. It was pleasing to see that these requirements had been met. It was also pleasing to see that the floor cover in the bathroom has been replaced, meeting a requirement of the last inspection. A further requirement was made at the last inspection that the tiles in the bathroom were to be replaced where the toilet roll holder had been removed. It was disappointing to see that the tiles had not been replaced. An attempt had been made to fill the holes, however the workmanship is shoddy, with
Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 16 rough areas that service users may scratch themselves on and the area appears unsightly. A further requirement has been made that these tiles to the left of the toilet in this bathroom are replaced along with one tile to the right of the toilet where the toilet roll holder was fixed previously. Other issues identified are as follows. The boxing in of the pipes in the toilet between rooms two and three, has become unsecured, is broken and has rough wooden edges that may cause splinters, this must be replaced. The radiator cover in room two is broken and must be repaired or replaced. Requirements have been made to address these issues. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Service users are supported and protected by the home’s recruitment policy and practices, and appropriately trained staff meets service users’ needs. EVIDENCE: The home has a policy and procedure in place for recruiting members of staff that is in line with current legislation and adult protection procedures. Personnel records were seen for several staff members and found to contain all necessary checks and information required to ensure the safety and wellbeing of the service users. A requirement was made at the last inspection on 27th June 2005 that the members of staff escorting service users in the hydrotherapy pool at the day centre must be competent swimmers with life saving skills. The manager stated that all members of staff escorting service users are strong swimmers and all service users have risk assessments in place for using the pool and wear life jackets when in or beside the pool. All members of staff in the home hold first aid certificates, all sessions are on a one to one basis and there is always one member of staff at the side of the pool to summon assistance if needed. The pool supervisor (not employed by the home) is a qualified lifeguard. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 18 The inspector feels that the above measures are appropriate and sufficient to minimise the risk of drowning to service users, given that the pool is under four feet in depth at the deepest point and service users are not left alone at any time and has agreed to remove this requirement. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 The views of the service users underpin the self-monitoring, review and development of the home. EVIDENCE: Welmede Housing Association has recently introduced a service user customer satisfaction questionnaire that has been circulated to service users, their families and involved professionals. The manager reported that feedback from this survey has been positive. Monthly quality assurance audits are carried out by, senior managers and copies of these are sent to the Commission. Welmede also hold residents and advocates meetings for all service users and/or relatives to air their views. The manager seeks the views of service users’ friends and family and a record of all comments made is maintained. The inspector was able to see several letters from service users’ friends and family complimenting the home and staff team on the care and services provided. Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Sandalwood Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000013777.V268938.R01.S.doc Version 5.0 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 24 Regulation 23 (2) (d) Requirement The wall tiles either side of the toilet in the bathroom must be replaced where the toilet roll holder has been removed. The wooden boxing covering the water pipes in the toilet between rooms 2 and 3 is unsafe and must be replaced. The radiator cover in room 2 is broken and must be repaired or replaced. Timescale for action 31/01/06 2 24 23 (2) (d) 31/01/06 3 24 23 (2) (d) 31/01/06 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 Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Sandalwood DS0000013777.V268938.R01.S.doc Version 5.0 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. 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!
