Inspection on 01/02/08 for Sandalwood Court

This inspection was carried out on 1st February 2008.

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

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

Sandalwood Court 30/07/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandalwood Court Butland Road Oakley Vale Corby Northants NN18 8QA Lead Inspector Kathy Jones Unannounced Inspection 01 February 2008 09:30 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 Sandalwood Court DS0000070474.V355082.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. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandalwood Court Address Butland Road Oakley Vale Corby Northants NN18 8QA 01536 424040 01536 747890 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) www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd Post Vacant Care Home 60 Category(ies) of Dementia (60), Dementia - over 65 years of age registration, with number (60), Old age, not falling within any other of places category (60) Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE and DE(E) The maximum number of service users who can be accommodated is: 60 This is the first key inspection. 2. Date of last inspection Brief Description of the Service: Sandalwood Court is a purpose built residential home opened in August 2007. Sandalwood Court is a residential home providing personal care for up to 60 older people including people with dementia. There are bedrooms, lounges and dining rooms on each of the three floors with twenty residents accommodated on each floor. There is a passenger lift, which provides people with access to all floors. Sandalwood Court is situated in the centre of a new housing estate on the outskirts of the town of Corby. All of the people residing at Sandalwood Court are placed there under a contract between Northamptonshire County Council and Shaw Healthcare. The fees are agreed as part of this contract and paid by Northamptonshire County Council. Fees are dependent on assessed needs. Currently there are three fee levels, which are linked to the residents’, assessed needs as follows: Low £444.84 per week, medium £465.54 and high £486.24. The fee paid by Northamptonshire County Council includes the cost of accommodation, meals, laundry and personal care. Additional costs were identified as personal items, such as toiletries, clothing, newspaper and private Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 5 chiropody treatment. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls and any complaints received. The information gathered assisted with planning the particular areas to be inspected during the visit. Sandalwood Court is a relatively new service being registered on 6th August 2007. An inspection visit was carried out on the 16th August 2007 to specifically look at concerns that had been raised about staffing levels. The findings of that visit and requirements made at that time were taken into account as part of the inspection planning. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and views on the care provided were sought from people who use the service, some relatives who were visiting and staff. Additionally questionnaires were sent to a random selection of people to ascertain their views. Responses were received from two staff members, three health professionals and three relatives. Their views have been considered as part of the inspection and some comments incorporated within the report. The management of residents’ medication was checked through reviewing the medication for one person randomly selected and discussion with staff from another service who were carrying out a full medication audit. Recruitment procedures were also considered through looking at electronic records for a member of staff. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 7 Communal areas and a sample of bedrooms were viewed and observations were made of people’s general well being, daily routines and interactions between staff and people who use the service. Verbal feedback was given to the Interim Manager throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: While information is available about the service, details of the fees would help people in making informed choices about their care. Prior to admission full assessments of people’s care and health needs must be carried out and information gathered about daily lives, preferences and Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 8 religious and cultural needs to help staff understand what support and assistance people need. Care plans need to be put in place for all people to help guide staff in providing the care that people need and want and to ensure that all staff are being consistent in the way they help people. Better review and monitoring of people’s health care needs and management of their medication is needed to maintain people’s health and well being. A more thorough approach to investigating, responding and acting on complaints would help to improve the service provided and better protect people. Concerns about inadequate staffing levels were raised at the inspection in August 2007 and requirements were made. While assurances were given that action would be taken, feedback in surveys indicates that this has been an ongoing problem. Strong leadership and management would help in meeting the needs and protecting the health and welfare of people who use the service. A more honest and accurate approach towards the completion of quality assurance self assessments would provide a better basis for making improvements. 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. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 9 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 Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 10 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): 1, 3, standard 6 was not assessed as intermediate care is not provided. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The admissions process provides no assurances that people’s needs, can be met. EVIDENCE: Written information is provided in the form of a statement of purpose and a service user guide. The service user guide was prominently displayed on the notice board in the entrance hall. A copy of the statement of purpose was forwarded to The Commission for social Care Inspection following the inspection and the Interim Manager confirmed that this would be displayed alongside the Service User guide. This is the first key inspection since registration, however the Interim Manager confirmed that when published, a copy of the inspection report would be made available alongside the Service User guide. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 11 A sample check of the information within the above documents identified that the documents provide prospective residents and their families with clear information about the facilities, staff, and the care provided. However information about fees and additional charges needs to be included to help people who currently use the service and those who may in future make decisions about their care. Shaw healthcare have various assessment tools and documents, which are used to gather information to enable a decision to be made, firstly as to if the needs of a prospective user can be met, and secondly to identify the care that is required to meet their needs. Review of the records for someone who has been recently admitted identified that assessments had not been completed or in some cases only partially completed. Even basic information such as date of admission, ethnic origin, religion and the address of the next of kin were missing. The activities of daily living assessment, which is designed to ascertain people’s basic needs, had also not been completed. The lack of information makes it very difficult for staff to meet the needs of people, particularly those with dementia who may be unable to express their needs and wishes. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 12 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, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The shortfalls in the planning of care and instruction to staff about the care and health needs and management of medication for people who use the service has the potential to put them at risk. EVIDENCE: People who use the service and some visiting relatives spoken with during the inspection were satisfied with the care being provided. A survey from one relative said that they were always kept up to date with important issues and that they were satisfied with the care, while comments from others indicate that they are not happy with the level of support and care. These comments in the main link with concerns raised about staffing levels and are addressed in the staffing section of the report. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 13 An annual quality assurance self assessment submitted to the Commission for Social Care Inspection in December 2007 stated “New care plans have been developed to provide clear risk assessments and plans of care to enable staff to provide a consistent and person centred care.” It also stated that “care plans are evaluated monthly and changed accordingly monthly or when a residents needs change.” It was therefore of particular concern that a review of a sample of care files for three people using the service identified that there were no care plans in place for two of the three people. Care plans are considered to be important documents to provide guidance to staff as to the actions they need to take to meet peoples’ care needs. Discussion with staff and observations during the inspection identified that there are not sufficient permanent staff and that it is necessary to use agency staff. This makes it even more important to ensure that care plans provide detailed and clear information about residents current care needs to ensure that they are met. A member of staff said that staff were having difficulty meeting the needs of a newly admitted person with dementia who was resistant to staff trying to assist with personal care. Review of the care file identified that there were no care plans in place and no guidance at all for staff as to how best to meet the persons needs. The lack of guidance increases the risk of staff adopting different strategies resulting in inconsistent care and increased confusion and possible distress for the person using the service. Review of the daily records for a person using the service raised concerns about how peoples’ health care needs are monitored and supported. For example three days after someone was admitted there was a record, which stated “tummy folds and groins very red and sore, needs District Nurse tomorrow to prescribe cream.” Ten days later on the day of inspection there was no evidence that a District Nurse had been contacted or of any cream being prescribed. A member of staff advised that the condition was now improving, however this apparent failure to seek advice and make referrals to health professionals puts people at risk of their health deteriorating. The need for more careful monitoring of people’s health is supported by a survey received from a health professional. This identified that they had concerns that one of their diabetic patient’s blood sugar was low and the carers were not sure what they had eaten. Not knowing if, when and what had been eaten may have affected their health significantly. During a sample check of medication for a person using the service, it was identified that their prescribed medication had not been checked and recorded on admission. One of the medications detailed on the medication administration records as prescribed was not in stock and a staff member had recorded on 26/01/08 “can’t find”. There was no evidence that the pharmacist Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 14 or General Practitioner had been contacted regarding this, however this was done during the inspection. Entries on the medication administration records for another medication identified several refusals. Discussion with a staff member regarding this identified that if asked if she wanted medication the resident was likely to say no, however if offered the medication with a positive approach she would usually take it. This again highlights the importance of good care planning to guide staff. Discussion with staff about the concerns relating to medication identified that a manager and another senior member of staff from Shaw Healthcare had been brought in to Sandalwood Court to carry out a full audit of every resident’s prescribed medication. This was as a result of concerns that the organisation had identified in relation to the management of medication. While discussion with staff identified that the audit was highlighting a range of shortfalls relating to storage, record keeping, ordering, auditing and administration they confirmed that urgent issues were being addressed as they were identified and recommendations would be made for improvements based on the findings. Given the extent of the shortfalls the interim manager has been asked to forward a copy of the report to the Commission for Social Care Inspection to confirm the action that is being taken to reduce the risk to people who use the service. People who use the service spoken with during the inspection were satisfied with how they were spoken with and treated by staff. During the inspection staff were observed to speak courteously to people and respond appropriately to them. People confirmed that personal care is carried out in the privacy of their rooms. However a survey from a health professional identified that some staff do talk over people sometimes. A District Nurse had suggested to one of the people that she was visiting that tights or stockings may give her legs a little extra protection. The majority of the ladies were not wearing stockings or tights, however from the people spoken with it was difficult to establish the reason for this. Advice was given to include information within individual care plans in relation to personal preferences in relation to dress as this is an important factor in maintaining dignity. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 15 Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 16 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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are activities and flexible visiting arrangements and most people are happy with the food. However more could be done to ascertain and provide for individual needs and choices and for those people who are less independent. EVIDENCE: There are some regular activities, which are provided such as gentle exercises, bingo, reminiscence sessions, singers, and Pets as Therapy (PAT dogs). Residents spoken with were unable to recall specific activities, however on the afternoon of the inspection a number of residents were enjoying a film with ice cream served in the interval. A survey from a relative stated “They make them feel at home and entertained”, while a health professional felt that people needed more stimulation as they said they just sit in chairs and watch television. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 17 As detailed in the health and personal care section care plans reviewed were either not completed or not fully completed. There was therefore little or no information about people’s background, interests, and cultural or religious needs. The activity organiser advised that she was going to attend some dementia training to help provide appropriate activities and stimulation for people with dementia. However there was evidence that there is a lack of understanding by some staff carrying out assessments of the importance of gathering information about the Background, life and interests of people with dementia. One document titled ‘background and social information included the comment “not completed due to Alzheimer’s.” Visiting arrangements are flexible and residents’ confirmed that their visitors are made welcome. This is important in encouraging friends and relatives to visit as the visits help to enhance residents’ daily lives. The level of choice and control that people have over their daily life seems to depend on how independent they are. For example a relative highlighted that people who need assistance with their meals often have to wait, as there are not enough staff to serve the meals and assist them. This highlights the need to review staffing levels based on the dependency needs of people. People spoken with said that they have choices in relation to things such as their meals. Meal times were being altered partly due to peoples’ preferences and partly due to the fact that the gap between breakfast and lunch was quite small and then there was a long gap between tea and breakfast. The alterations should also help reduce the risk of weight loss as it had been identified that people having late breakfast often didn’t eat lunch. People spoken with were generally satisfied with the meals provided. Lunch on the day of inspection was a choice of fish, chips and mushy peas or egg and chips. The Interim Manager advised that along with the changes to meal times, menus would be reviewed to ensure they are based on people’s choices and are nutritionally balanced. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 18 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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaint and safeguarding procedures are in place and people are aware of how to raise concerns. However a more thorough and consistent approach to exploring the detail of peoples concerns, responding to them and acting on them is needed to properly safeguard people who use the service and improve standards of care. EVIDENCE: Information about how to make a complaint is detailed within the statement of purpose. Contact details are provided for the regional office, which provides people who do not wish to raise concerns directly with staff in the home, the opportunity to raise issues. Contact details are also provided for the Commission for Social Care Inspection and the Ombudsman. Given that Northamptonshire County Council have a responsibility for the people placed at Sandalwood Court who are all placed under contract, it would also be helpful for people to have information about how to raise a complaint directly with them. Surveys from three relatives/advocates identify that they all know how to make a complaint; two said they are usually responded to appropriately, while the third says they are never responded to appropriately. An additional Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 19 comment was made, “I have made a number of complaints to stand in managers none of which have been followed up with communication to me”. The Commission for Social Care Inspection received three complaints within a few days of the home being opened on 6th August 2007. The complaints were about inadequate staffing levels, care practices in relation to two residents and lack of support for a resident with dementia attending a hospital appointment. The Commission for Social Care Inspection carried out an inspection on 16 August 2007 with a view to looking at the adequacy of staffing levels. A statutory requirement was made regarding the need for there to be sufficient staff to meet peoples needs. Shaw Healthcare Ltd investigated and acted appropriately on the care issues raised in consultation with social services through the safeguarding adult procedures. The annual quality assurance self assessment submitted to the Commission for Social Care Inspection in December 2007 states that ten complaints had been received and that none of these were upheld. From review of the record of complaints at Sandalwood, no evidence could be found that the complaints made were not founded. For example they included complaints about staffing levels and lack of clean laundry and the action to be taken was recorded as being to recruit more staff. There was no evidence that a response had been provided to the complainant. A complaint in the record for September 2007 raises concerns about staffing levels and staff “being rude”. The action being taken is recorded as employing more staff. There is no evidence of any exploration of what the actual outcome for people who use the service was or what staff being rude meant. It is important that such issues are discussed to ensure that appropriate action can be taken to safeguard people. During this inspection there was evidence that the current Interim Manager was making himself available to people who use the service and listening to their concerns. The organisation has demonstrated that they will act to protect people who use the service and staff while an investigation into allegations takes place. People who use the service and relatives spoken with during the inspection had no concerns about how they are treated by staff. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 20 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, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Sandalwood Court has been built to a high standard and provides a pleasant and comfortable environment for people with adaptations which meet their needs. EVIDENCE: Sandalwood Court is a new building, which opened on 6th August 2007. It has been built to a very high standard and is quite spacious with good natural light. There are three floors with twenty people accommodated on each floor. Each of the floors consists of two ten bedded units which are linked. Each unit has an assisted bathroom, which is spacious and equipped to meet the dependency needs of residents. There is also an open plan lounge, dining room and kitchenette in each unit. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 21 Bedrooms provide for single occupancy, have en-suite facilities and are of a good size. They are comfortably furnished with good quality furnishings and residents’ are able to bring in personal items to individualise their rooms and provide a familiar environment. Sandalwood Court is fully accessible to people with physical disabilities and specialist equipment and adaptations have been fitted in the new building. All areas of the home were clean and smelled fresh at the time of the inspection. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 22 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and recruitment procedures were not providing adequate care and protection for people who use the service at the time of the inspection. EVIDENCE: Comments received from relatives, health professionals and staff all include concerns about staffing. Comments include: “Never enough staff, you cannot find them. Staff not available to pick up urgent prescriptions”. “This home is working with mostly agency staff who do double shift and I feel do not have the time or patience for the residents”. “Complaints not with the carers just the lack of them. 6 months down the line and there has been little or not much improvement with the number of carers to the numbers of residents.” “No continuity of team leaders, which has a bearing on the care. No time to talk just to do what is necessary”. There is currently a heavy reliance on the use of agency staff, however discussion with two agency staff identified that they had been working Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 23 regularly at Sandalwood Court and had got to know the routines and the people who live their. From observations, review of records, discussion with staff during the inspection and review of the comments, which are summarised by those above, it would appear that many of the shortfalls identified during the inspection might be linked to staffing. Following the inspection the Interim manager has confirmed in a telephone conversation that staffing levels have been increased. One of the improvements is that there is now a team leader based on each of the three floors. This if sustained should help to improve the monitoring and oversight of people’s health and care needs and staff retention leading to more consistent care. Surveys received from two staff and discussion with a staff member during the inspection confirmed that appropriate training is provided. Electronic records reviewed for a recently recruited member of staff confirmed that they had received induction training and training in safe working practices such as food hygiene, infection control, health and safety and movement and handling. A staff member also advised that they were about to commence some dementia care training. The Interim Manager confirmed that staff training needs, were going to be reviewed and that as a result of the findings of the medication audit this would include medication training. Records relating to staff recruitment are stored electronically and are password protected for security. Review of the records for one recently recruited member of staff with the Interim Manager confirmed that criminal record bureau clearances are undertaken and references obtained. However there was evidence that there is a need to review information received in the application more thoroughly and check out any discrepancies. For example, information given referred to working in a hospital, whereas there was no reference to a hospital in the employment history and no employment references had been sought. It is important in helping to protect people who use the service that a full employment history is obtained and that references are sought from an employer and particularly where the work has been with other vulnerable people. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 24 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): 33, 25, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sandalwood Court needs strong leadership and management to meet the needs and protect the health and welfare of people who use the service. EVIDENCE: Standard 31 relates specifically to the Registered Manager and their experience and qualifications. The Registered Manager in post at the time of registration on 6th August 2007 was absent from the end of August and has since left. However this standard is considered from the perspective of the adequacy of the management arrangements, as this is considered a key aspect of ensuring that residents receive appropriate care. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 25 In the absence of a registered manager, responsibility for the management of the service lies with the organisation. Managers from other Care Homes have provided some temporary management cover. However the findings of this inspection confirm that the arrangements to date have not been sufficient to support the health and welfare of residents. Several comments have been made within the surveys received and during the inspection about the difficulties of not having a permanent manager and this one sums up views expressed about what is needed “more continuity and permanent manager to take responsibility for all the things that need to be rectified.” As detailed in the complaint section of this report an inspection was carried out soon after registration in August 2007 as a result of complaints received. A very positive response was received from Shaw Healthcare Ltd to the concerns that were raised and reassurances given about addressing the shortfalls. It is therefore of particular concern to find similar concerns some six months later and unmet requirements relating to staffing levels and care planning. An annual quality assurance self assessment submitted in December 2007 does not reflect accurately the shortfalls identified during this inspection. An honest approach to completing the quality assurance assessment tool is important for identifying and making improvements. Shaw Healthcare Ltd has now brought in an Area Manager from another area as an Interim Manager tasked with addressing the shortfalls and raising standards. He has also confirmed that he will be inducting and supporting a new Manager who is due to commence work towards the end of March 2008. There was evidence that the Interim Manager is engaging with people who use the service, relatives and staff and has plans for making improvements. There are systems in place to hold small amounts of money to assist people with paying for things such as hairdressing and chiropody. A sample check was made of the system and records and receipts were in place to confirm each transaction. This helps to safeguard people who use the service. At the time of the inspection a free standing radiator was found in one of the corridors outside a residents room apparently due to a problem with maintaining an adequate temperature at night at the end of some corridors. The radiator was too hot to touch, posing a risk of burning to anyone who may fall. The Interim Manager confirmed that the heating engineers were addressing the problem and in the meantime would put in place measures to reduce the risk. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 26 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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 2 X 3 X X 2 Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 5 Requirement Timescale for action 30/03/08 2. OP3 3. OP7 4. OP7 The Service User Guide must contain all information detailed in Regulation 5, including clear information about all charges. This would help prospective and current people who use the service and their families make informed decisions. 14 Prior to admission a full 30/03/08 assessment must be carried out to identify peoples needs and expectations to ensure that they can be met. 12 (1) (a, Care plans and risk assessments 18/04/08 b), 15 (1), must be reflective of the current 15 (2) care needs of people who use the service and be reviewed regularly. (A requirement with a timescale of compliance of 30/11/07 has not been met) 12 (1) (a, Care plans must provide the 18/04/08 b) basis for the care delivered with staff being aware of their content to ensure appropriate and consistent care. (A requirement with a timescale of compliance of 30/11/07 has not been met) DS0000070474.V355082.R01.S.doc Version 5.2 Sandalwood Court Page 28 5. OP8 12 (1) (a), 13 (1) (b) 6. OP9 13 (2) 7. OP9 13 (2) 8. OP9 17(1)(a)( b) Arrangements must be in place to ensure that people’s health needs are monitored and advice and where appropriate treatment is received from health professionals. Prescribed medication for people who use the service must be available and administered as prescribed. People who use the service must receive the support they need with their medication. Where a person using the service is regularly refusing medication, there must also be evidence that a General Practitioner has been consulted. People who use the service must have records of medicines received on their behalf fully and accurately recorded at all times. There must be an audit trail to demonstrate the receipt, administration and disposal/return for each prescribed medication. Arrangements must be in place to ensure that people’s needs in relation to culture and religion are known and supported. There must be evidence that all complaints are fully investigated, responded to and shortfalls acted on. There must be sufficient staff on duty at all times to meet the needs of people who use the service. (A requirement with a timescale of compliance of 30/08/07 has not been met) Information received as part of the recruitment process for staff must be more thoroughly reviewed to ensure that a full employment history and DS0000070474.V355082.R01.S.doc 30/03/08 30/03/08 30/03/08 30/03/08 9. OP12 12 (4) (b) 18/04/08 10. OP16 22 (1) (3, 4) 18 (1) (a) 30/03/08 11. OP27 30/03/08 12. OP29 19 (1) (b) (i) 30/03/08 Sandalwood Court Version 5.2 Page 29 13. OP33 24 14. OP38 13 (4) (c) appropriate employment references have been obtained. This is to help protect vulnerable people. All quality assurance assessments including those submitted to the Commission for Social Care Inspection must provide an accurate reflection of the service provided and be used as a tool for making improvements. Prior to the use of free standing heating appliances a full risk assessment must be carried out and arrangements made to ensure people are not exposed to the risk of burning. 18/04/08 14/03/08 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. 2. 3. Refer to Standard OP10 OP12 OP31 Good Practice Recommendations Individual preferences in relation to the wearing of stockings or tights should be included in people’s care plans. Information should be gathered about people’s interests and preferences to help from the basis for individual activity plans. Efforts should be made to maintain and support effective and consistent management arrangements. Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Sandalwood Court DS0000070474.V355082.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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