Inspection on 12/06/08 for Sandfield House

This inspection was carried out on 12th June 2008.

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

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

Sandfield House 17/07/07

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sandfield House Sandfield Avenue Headingley Leeds West Yorkshire LS6 4DZ Lead Inspector Catherine Paling Key Unannounced Inspection 09:45 12th June 2008 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 Sandfield House DS0000069132.V364353.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. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandfield House Address Sandfield Avenue Headingley Leeds West Yorkshire LS6 4DZ 0113 2752977 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) Mr Ibrar Zahir Mrs Jane Crawley Care Home 27 Category(ies) of Dementia (27), Dementia - over 65 years of age registration, with number (27), Mental disorder, excluding learning of places disability or dementia (27), Mental Disorder, excluding learning disability or dementia - over 65 years of age (27) Sandfield House DS0000069132.V364353.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: Dementia - Code DE and Code DE(E); Mental Disorder, excluding learning disability or dementia - Code MD and Code MD(E) The maximum number of service users who can be accommodated is: 27 17th July 2007 2. Date of last inspection Brief Description of the Service: The home is situated in the Headingley area of Leeds within walking distance of shops and local amenities and close to a main transport system into the city centre. There is off road parking at the side and to the rear of the building. The home provides personal care only for people with dementia. Nursing support is provided if needed by the community nursing services. The building is a large converted detached house with an extension, which stands at the head of a cul-de-sac backing onto a large garden. There is accessible outdoor space is not currently secure enough to enable people who live in the home to walk about outside unaccompanied. The majority of rooms are for single occupancy with four shared rooms. One room has en suite facilities. There are a number of communal bathing, showering and toilet facilities situated throughout the building. The current fees range from £447.27 to 470.41 per week. This does not include hairdressing, chiropody, personal toiletries and clothing, newspapers or taxis. A small charge is made if staff are required to escort people to hospital. The manager provided this information at the June 2008 visit. The home should be contacted directly for up to date information about charges. Information about the service is available from the home in the form of a Statement of Purpose and Service User Guide. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:45 until 16:10 on 12th June 2008. The purpose of our inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection we looked at accumulated evidence about the home. This included looking at any reported incidents, accidents and complaints. We used this information to plan the visit. We looked at a number of documents during the visit and visited all areas of the home used by the people who live there. We spent a good proportion of time talking with the people at the home as well as with the manager and the staff. We asked the home to provide some information before the visit by completing an Annual Quality Assurance Assessment (AQAA). We sent survey forms to the home before the inspection providing the opportunity for people to comment on the service, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A small number of surveys were returned and some of their comments are included in the report. What the service does well: The manager provides clear leadership and direction to the staff and is readily accessible to relatives and the people living at the home. The home provides a warm and welcoming environment to the people who live there. Pre-admission assessments are done so that the home can be confident that they can look after people properly. The admission process is managed well with one relative saying that she ‘can’t believe how well it’s gone’ and that the ‘staff are very friendly, brilliant’. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 6 Care plans have good detail of how to look after people including good personal information to help staff understand the people they are looking after. Families also feel involved and welcomed at the home at any time. People said: • Senior personnel have a deep understanding of my fathers needs and are very supportive to myself and my family. I know my father is cared for and that brings peace of mind to a very distressing situation. • Treats their residents as respected individuals, creates a family atmosphere • As they have always involved me in decisions about my mother I have never felt the need to raise concerns as communications are so good and the home usually identifies any problems and we find solutions together. There is a good working relationship with visiting healthcare professionals with one GP saying that they ‘look after people well’. Staff are knowledgeable about the people living at the home and we saw them carrying out their work with great patience. People are made aware of how to complain and staff training and awareness about safeguarding means that they are safe in their surroundings. What has improved since the last inspection? What they could do better: The manager does not have any specialist training in dementia care. We have again recommended that she undertakes a certificate or diploma course in dementia care to keep up to date with current practice and continue to develop the home in a person centred way. People living at the home would benefit from a wider variety of activities and stimulation. The manager is aware of this and is trying to find a suitable person to organise activities in the home. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 7 The manager should arrange for staff to have annual update in the administration of medication to make sure that people are protected at all times by safe and up to date medication practices. The manager and her staff should continue to work at developing the care records to make sure that they provide accurate detail about care so that staff can look after people properly. The manager should review the current nutritional risk assessment tool as it does not appear to give an accurate picture of people’s nutritional risk. If risk is not properly assessed people could be put at risk. Although some refurbishment of the premises has taken place this should continue with particular regard to the lounge seating which was looking worn. A variety of seating should be considered. Recommendations appear at the end of this report. 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. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 8 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 Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 9 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 and 3 (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. All people have their needs assessed before they are admitted to the home. The information available to people and their families gives them the information they need to decide if they want to move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states: • Service users and relatives are invited to visit the home • All residents are assessed before admission and feedback is given to them or their next of kin and the social worker if applicable Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 10 • • • Prospective residents are invited to stay and ‘sample the home’ before making a decision Service users’ guide is provided after admission to the home – this is one thing the manager sees as requiring action and there are plans to provide the guide before admission There is a new brochure People said: • Its a long time since I moved in but I remember coming for my dinner and meeting other residents whilst looking around. We spoke with the relative of someone who was admitted to the home in February this year and she described the admission process. She had been able to visit the home at anytime before her mother was admitted to meet staff and to look round. The manager had visited her mother at home to assess her needs and she and her mother felt that they had all the information they needed to make the decision about moving into the home. She had been to stay at the home for respite before moving in permanently. Her mother had been very well supported to settle at the home and said she felt happy. Her daughter said that she ‘can’t believe how well it’s gone’ also saying that the ‘staff are very friendly, brilliant’ and that she would ‘certainly recommend it to anyone’. Another person had been admitted the previous day and there was a detailed pre-admission assessment together with information from other sources about the reasons this person was coming into care. There was enough detail to produce initial care plans describing what this person could do and what support they needed from staff. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. Overall, care plans have enough detail of the care people need so that staff are able to look after them properly. People are protected by safe medication practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • Care plans are completed with service user and relative and are signed • Healthcare professional visits are recorded • GP visits are recorded and families are made aware of visits • Escorts are always provided to hospital • Staff have respect for people and treat people with dignity. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 12 People said: • I am very happy at the home • Treats their residents as respected individuals, creates a family atmosphere, despite the difficult behaviour of some of the residents. • Overall standard of care is high and I feel that my mother is receiving appropriate care for her age and medical conditions. • As they have always involved me in decisions about my mother I have never felt the need to raise concerns as communications are so good and the home usually identifies any problems and we find solutions together. • I have watched them on my frequent visits handling patients - very professional, but always with that human touch, and when everyone always has such pressing needs - it is quite remarkable. I admire their respect for their residents and how they manage to retain their dignity. • (Communication) They are exemplary in this matter. Either a doctors visit, change of medication or care plan, always a phone call. Couldnt wish for better communications. • Receive phone calls if there has been any problem or appointments made e.g. hospital or CPN. • My mother has dual disabilities - dementia and visual impairment. Both conditions have any needs met e.g. referral to GP if required. Also personal dignity is maintained - Mum is always clean and well dressed. • Feel absolutely that Sandfield house and all the staff give 150 to all their residents and treats them as dignified individuals. One relative who had been a carer for a number of years before her mother came into care spoke of the support she had from staff and how she worked with them on occasion to care for her mother. She had occasionally come and helped her mother to bed and clearly felt that she was able to visit at anytime, even quite late and can be involved in looking after her mother. Relatives said that they were always kept informed of any changes and called in the case of people being unwell. We were able to talk to the visiting General Practitioner (GP) during the visit. He visits the home regularly, once every two weeks and more often if necessary. There are generally about four of five people for him to see. He was very positive about the care provided at the home and the knowledge of the staff. He particularly commented on how well the home managed ‘end of life’ care working with the district nurses and the GP surgery. He felt that the staff called on the surgery ‘generally appropriately’ and that they ‘look after people well’. He also commented that the GPs get positive feedback from relatives. The medicine trolley was faulty and a replacement had been arranged. In the meantime additional security measures were being taken to make sure that Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 13 the drugs were held securely. We watched a medicine round and good practices were observed and it was well organised. People were helped to take their medicines in an unhurried way. Staff involved in the administration of medicines are supported by the manager and her deputy and complete training booklets provided by the pharmacy. There were no arrangements for update in medicine administration for staff and it was recommended to the manager that this should be provided annually to make sure that staff continue to observe good and safe practices. We looked in detail at the records of three people living at the home. Clear reasons could be found for why people had been admitted to the home and detailed ‘pen pictures’ gave staff good information about people’s lives and background. There was a whole range of risk assessments in place which included manual handling, the risk of skin damage and nutritional risk as well as whether there was a particular risk of someone wandering out of the building. Some people held their own bedrooms door keys and a risk assessment was completed for this to assess if this was appropriate or not. The nutritional risk assessment for one person indicated that this person was at low nutritional risk. This person had a very low weight, had dementia and was unable to drink unaided or to feed herself – this person was at considerable nutritional risk. Staff had not relied on the tool as we saw this person being helped with diet and fluids throughout the day. To avoid any confusion and to make sure people’s needs are properly identified, the manager was asked to review the nutritional risk assessment tool in use and to identify one which could be relied to give a more accurate assessment. There were records of fluid and dietary intake kept for some people but these were not always up to date. These records should be more accessible to staff so that they can be completed in a more timely way. It is not good practice to complete these at the end of a shift. GP visits were well documented and there were records of visits made by other healthcare professionals. The chiropodist was at the home and saw people in private in one of the smaller lounges. Care plans did contain some good personal detail about the specific needs of people. Information from assessments was used to develop care plans. For a recently admitted person it was identified at assessment that they ‘might be fearful’ of bathing and so initially two staff would be involved. This was because in hospital this person had only allowed her feet to be washed. Other plans provided information of what was known from assessment with instruction to add information as they settled and as staff got to know them better. Further detail was needed in some plans to make sure staff fully understand what is expected from them and how to look after people properly. For Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 14 example, ‘recent weight loss so will need to be observed’ – but there was no information on what to observe or how often this person should be weighed or if they should have any supplements. It was clear from observation that staff are knowledgeable about people living at the home. Staff were patient with people who seemed confident in their surroundings. Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. People are supported in maintaining contact with their family and friends and visitors are welcomed at the home. People are provided with a nutritious diet. The range of activities is limited and some people would benefit from more entertainment and stimulation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • Visitors are welcome at any reasonable time • Monthly communion • People are consulted about menus • Staff encourage socialising in small groups and for different activities Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 16 • • • • • • Craft afternoons, baking sessions and a motivation session every two weeks Involvement in activities is recorded on activity sheets in the records Currently advertising for an activity organiser for 5 days a week Minibus available for trips out Coloured crockery for those with vision problems Plans include – employment of activity organiser, raised flower beds, more trips out and continued encouragement for people to reach their potential. People said: • Meals – ‘Very good choice and getting better’ • Warm welcoming feeling at Sandfield • Care and warmth (towards residents) • Range of social activities seems to be dependant on staff available. I feel that sometimes staff could be more pro-active in involving residents in activities (group) - even those that have dual disabilities. • I was very happy about the homes interest in mums Jewish background. • As the staff are mixed race and faith - it seems to make it easier. My mothers religious needs have always been met and I have been involved at all stages and consulted. • They have encouraged actions that she can manage and helped on those tasks that she couldnt. The kindness shown by all staff is above and beyond the call of duty and in such difficult circumstances I dont know how they do it - exceptional. • Very happy at support given by all staff who are caring and sensitive to mums needs • Whenever I ring they always put mum near to the phone so that I can hear her response - very important when you live 200 miles away Relatives said that they were made very welcome at the home at any time of the day. They were able to stay for meals and were usually offered refreshments. There was clear evidence that staff work hard at making sure that people keep contact with their family and friends. People are encouraged to spend their time how they wish and there is a relaxed and homely atmosphere at the home. People were provided with drinks when they wanted, someone asked for a cup of coffee immediately before lunch and this was made for him. The lunchtime arrangements are such that people needing the most support are given their lunch first. More able people are then given their lunch. This means that the meal is more or less concluded at the same time for everyone. The whole mealtime is relaxed and unhurried with plenty of time for staff to help people appropriately. The cook serves the meal and knows people’s likes Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 17 and dislikes and appetites. She takes care not to over face people and second helpings were offered. Juice was given with the meal and a hot drink afterwards. A small group of people were sat around the table chatting. Other people were sleeping but were responsive when they were disturbed and there was something to do. It seems that people living at the home would benefit from a wider variety of activities and stimulation. The manager is aware of this and is trying to find a suitable person to organise activities in the home. There is a large garden to the rear of the home but work is needed to make sure that this is a safe area for people to wander in unsupervised. Sandfield House DS0000069132.V364353.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 and 18 People who use the service experience good quality outcomes in this area. People living at the home are listened to and their views are taken seriously. People can feel safe at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • Simple, clear and concise complaints procedure that includes timescales and stages of any investigation • Records are kept of complaints received, investigation and outcome • Advocates are arranged if needed • All allegations of abuse are followed up • Policies follow ‘no secrets’ guidance • Safeguarding training has been completed for carers – training records will show this • Plans to extend training to ancillary staff • QA questionnaire asks relatives if they know how to make a complaint People said: • From the first week I was informed of the procedure Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 19 People are aware of the complaints procedure. It is clear and includes timescales. The manager was able to show us records of complaints received together with information of how it has been dealt with. The manager is readily accessible to people living at the home and to relatives who find her approachable. The manager and a senior member of staff have completed safeguarding training to enable them to train the staff. The training takes the form of a video and questionnaire for staff. All care and ancillary staff have completed this training and those we spoke to were able to confirm that they knew what to do it they suspected abuse. The training has resulted in a raised awareness about safeguarding and open in-house discussion about the subject. Sandfield House DS0000069132.V364353.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 and 26 People who use the service experience adequate quality outcomes in this area. People live in a safe and comfortable environment. Ongoing refurbishment is continuing to make sure that people carry on living in comfortable surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • Safe, secure, well lit, homely environment • Endeavour to be odour free Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 21 • • • • Encourage people to furnish their rooms with their own furniture and pictures Large clocks and a calendar board in the communal area Colour identification for bedroom door surrounds and toilet and bathroom door surrounds Street name signs in corridors to help residents to find their bedrooms Improvements over the last 12 months include; • Colour identification areas • Redecorated kitchen • New carpets • Hand gel next to visitors book for people to use as they enter and leave the building We visited all parts of the home used by the people who live there. The toilets were clearly indicated and there were other signs and indicators around the home to help people find their way around. When the current owner took over the home there were some unexpected expenses, which has meant that redecoration and refurbishment has been slower than intended. Following discussion with the provider his commitment to the improvement of the environment was clear. We have asked that a written refurbishment programme be provided. He acknowledged that chairs in the lounge areas are in need of replacement. We have suggested that a variety of seating should be provided to cater for people’s differing needs. The flooring in the conservatory is also in need of replacement with one more easily maintained. The wooden floor looks shabby because of constant cleaning. There are several small lounges, which provide plenty of wandering space for people. There is a small very comfortable quiet lounge, which can be used if people want privacy. Bedrooms are kept locked and some people have their own keys. The staff help anyone who wants to go to their room in the day. The laundry is in the basement and although in need of refurbishment was clean and tidy. There are good practices in place for the control of infection. Sandfield House DS0000069132.V364353.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 and 30 People who use the service experience good quality outcomes in this area. The staff are well trained and people are looked after by competent staff. People are protected by robust recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • 2 references and CRB checks are done for all staff • More than 50 care staff have NVQ level 2 and more staff are completing NVQ 3 • Clear lines of responsibility • Regular staff meetings and newsletters to keep people in staff • Aiming for 100 NVQ 2/3 People said: • There are key members of the Sandfield house team who are dedicated and long standing, and are a credit to the reputation of care homes Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 23 • • • Senior personnel have a deep understanding of my fathers needs and are very supportive to myself and my family. I know my father is cared for and that brings peace of mind to a very distressing situation. Staff are a good mix of ages and race and this creates a very lovely atmosphere. They also treat relatives with the same care and kindness. Even the young staff or part time staff seen to have the range of appropriate skills The majority of staff have achieved a National Vocational Qualification (NVQ) in care at level 2 with the remaining few working towards completion. There is a commitment for staff to progress to complete NVQ at level 3. This means that a well-trained workforce looks after people and this is reflected in the comments received in surveys. There is a good level of training available to staff and they are keen to learn. There is no annual training plan as such and it was recommended to the manager that she should develop a written plan so that she can provide clear evidence of training provided to staff. Records of completed training are kept of individual staff files. We looked at a small number of staff files. The files were well organised and information was easy to access. All the required checks are completed before people start work at the home. The care staff are well supported by dedicated domestic, laundry and kitchen staff over the full seven day period. The whole staff team work well together and are knowledgeable about the people they care for. Summary by the manager from the AQAA: ‘Staff are enthusiastic about their work and as a result of training, supervision sessions and meetings and handovers they now see the home as offering a specialist dementia service’ Sandfield House DS0000069132.V364353.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): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. The management of the home is well organised and practices promote and safeguard the health, safety and well being of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: • Manager is a registered nurse and holds NVQ 4 in management • Good communication skills – handovers, meetings, newsletter • QA systems – annual surveys of healthcare professionals, service users and relatives Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 25 • Monthly audit of accidents/incidents • Monthly fire drills – records kept • Bedrails risk assessments • Supervisions for care staff every 8 weeks • 2007 AQAA was distributed to staff to get their opinions of the home Improvements over last twelve months: • Better auditing of QA systems • Results of surveys to all • New hoist over next twelve months The registered manager is a qualified nurse and maintains her registration with the Nursing and Midwifery Council (NMC) through regular update. However, as the home does not provide nursing care, regulation requires her to consult with the community nursing service where people at the home have nursing needs. She also holds an NVQ at level 4 in management. The manager does not have any specialist training in dementia care. We have again recommended that she undertakes a certificate or diploma course in dementia care to keep up to date with current practice in this area of care and continue to develop the home in a person centred way. The home does not hold or manage any money on behalf of the people who live there. They keep records and receipts for any purchases made and these are then invoiced to families or representatives. Surveys are sent out annually to relatives and other healthcare professionals. The current survey was completed in May 2008. The results have been collated and produced together with details about action taken in response to comments. It was clear from the information we saw that the manager is proactive in her approach and acts promptly to resolve any issues raised. The manager also completes a monthly audit of accident and incidents occurring at the home. The audit is used to identify any trends or issues so that steps can be taken to reduce accidents. If forms have not been fully completed this is also identified. The manager has also been surveying people to see the level of interest in starting a relatives’ group. There has been a reasonable response and now the most convenient time for the majority of people is being identified. The manager works with her staff and provides a good role model with her approach to people and the support she gives. Sandfield House DS0000069132.V364353.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sandfield House DS0000069132.V364353.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 4 Refer to Standard OP7 OP9 OP12 OP15 Good Practice Recommendations Care records should continue to be developed to make sure that they provide accurate detail about care so that staff can look after people properly. Staff should have an annual update in the administration of medication to make sure that people are protected at all times by safe and up to date medication practices. More activities should be provided. People living at the home would benefit from a wider variety of activities and stimulation. The current nutritional risk assessment tool should be reviewed to make sure that people’s nutritional risk is accurately assessed. If risk is not properly assessed people could be put at risk. The manager should consider undertaking specialist training in the care of people with dementia. This is in order to keep up to date with current good practice and to be able to continue developing the home in a person centred way. DS0000069132.V364353.R01.S.doc Version 5.2 Page 28 5 OP31 Sandfield House Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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