CARE HOMES FOR OLDER PEOPLE
Sandfield House Sandfield Avenue Headingley Leeds West Yorkshire LS6 4DZ Lead Inspector
Sue Dunn Key Unannounced Inspection 17th July 2007 11:15 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.V346164.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.V346164.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 Imran 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.V346164.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 uers’ 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 New service 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 building is a large detached house with an extension, which stands at the head of a cul-de-sac backing onto a large garden. The 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. Some work is being done to make the environment more suitable for people with dementia so that they can retain a level of independence. The current fees are £1,660 to £1,828 per month. 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. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcomes for service users. The inspection report is divided into separate sections with judgements made for each outcome group. The judgements reflect how well the service delivers outcomes to the people using the service. The categories are “excellent”, “good”, “adequate” and “poor”. More detailed information about these changes is available on our website – www.csci.org.uk. This was the first inspection since the home changed ownership earlier this year. The manager completed a self-assessment questionnaire (AQAA) and this information, along with information supplied since the last inspection was used as part of the inspection process. Questionnaire leaflets were sent to the home requesting people who live in the home and their relatives to comment on the service. Three had been returned at the time of writing by relatives of people living in the home. More were left at the home to be handed out to visiting health professionals and relatives. One inspector carried out the unannounced inspection visit arriving at 11:30 am and leaving at 17:15 pm. During the visit, the inspector spoke to staff, the proprietor, the manager and deputy manager and a visiting Community Psychiatric Nurse (CPN). The care records of three people were examined carefully, staff records and other documentation was examined, there was a tour of the building, and some observation of care practices. People living in the home had a diagnosis of dementia, therefore had varying levels of communication. Some were asleep. Several were spoken with and observed. None of the people seen appeared to be in a state of ill being. Good practice recommendations at the end of this report advise on ways in which the home can continue to improve their specialist service. What the service does well:
The new proprietor has dealt with the requirements and recommendations identified at the last inspection and was receptive to suggestions made during the inspection. People who live in the home have their physical and health care needs well met and some work has been done to reflect the specialist dementia care the home provides. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 6 The home has a very detailed statement of purpose and those people who returned survey forms felt they had received good information when making a choice about the home. The home’s pre admission assessments indicated staff took a genuine interest in finding out about the people they were assessing so that each person would be cared for as an individual. The assessments included some background information about past lives, interests and skills. Care files were consistent in layout making information easy to find. Health care records were up to date and it was evident that there was good communication between staff and visiting health professionals. People living in the home were neatly dressed in their own style of clothing with attention given to hair and nail care. Staff were observed to be pleasant, talking to people and involving them in their conversations. The home provides a varied and nutritious menu, which is substantial and offers choice. It was good to see a cooked option available at teatime. Arrangements were in place for meeting cultural dietary needs. The cook keeps a list of birthdays to ensure these are celebrated and has day-to-day contact with people to observe their likes and dislikes. Relatives were aware of the complaints procedure. The home has access to an advocacy service for those people in the home who require representation to ensure their rights are protected. The home is making efforts to make the environment more suitable for people with dementia with the use of large clocks, which were accurate, daily updated information boards about the day, date and weather, good clear signs to identify toilet doors and a mirror mounted on an outside door to divert anyone wanting to get out of the front door. All such methods are good practice as they help people find their way about the home, act as prompts and reduce anxiety levels. The laundry was tidy and very clean indicating that attention is given to ensuring personal clothing is well cared for. This was born out by the appearance of the bedding and clothing of people living in the home. The proprietor was receptive and enthusiastic about suggestions that could improve the environment further. Some areas of the home lack natural ventilation. Despite this the staff do a good job of keeping the home free from unpleasant odours. Some of the bedrooms were very spacious with French doors onto balconies overlooking the garden. This allows plenty of space for people to furnish their rooms with personal possessions. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 7 The manager makes rigorous checks to make sure overseas staff employed by the home have authorisation to work. The home has exceeded the minimum 50 ratio of staff with a National Vocational Qualification (NVQ). Survey results stated that relatives felt staff ‘usually’ had the skills and knowledge to meet the needs of people living in the home. What has improved since the last inspection? What they could do better:
The Service user Guide was up to date but could be improved when next updated by including colour and visual prompts to make it easier for the people for whom it is intended to read and understand. A relative suggested that the provision of a cordless phone would make it easier for people to keep in touch with their families and friends. There were no visitors on the day of the visit. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 8 Freedom of movement in and out of the building is restricted as the garden and patio areas are not secure enough to avert the risk of anyone leaving the home and getting lost. Both are pleasant areas and it is strongly recommended that these areas be made safe and secure so that people can have the freedom to go into the garden without having to rely on staff being with them. Activities could be more person focussed if each person had a social and recreational care plan based on their interests, skills and abilities. Any complaints brought to the attention of the manager should be logged and there should be evidence to show how complaints have been handled. The manager and a senior care worker had completed the local authority Adult Protection training but staff had not yet had the training. There should be evidence to show that all staff have had adult protection training to ensure people living in the home are protected at all times. This should be given high priority. Carpets are to be replaced when the redecoration programme is completed. The proprietor acknowledged that lighting in some of the corridors and toilets was not adequate for people with poor eyesight and cognitive abilities. He said the lighting would be replaced in those areas. Many of the pictures around the home were faded and lacking in impact. It is recommended that these be replaced with more colourful eye-catching pictures and objects, which will further identify one area from another and provide visual stimulation. Those bedrooms with French doors are very pleasant but apart from a small sliding vent at the top of the doors have no means of ventilation other than by opening the door. It is recommended that the proprietor look at a solution to this so that windows can be safely opened whilst people are in their room. The manager’s accident audit identified times when there had been staff shortages. Existing staff were said to be covering vacant shifts but vacant posts must be filled as a matter of urgency to ensure staffing levels are consistent at all times. Some improvements could be made to the staff selection process to make sure the home meets its commitment to equal opportunities. It is recommended that interviews be carried out by more than one person and that all appointments (including internal applicants) are subject to satisfactory interview. The manager was competent and knowledgeable about the people in her care. However, in order for the home to continue to develop as a person centred specialist service the manager should consider undertaking a specialist training course in dementia care suited to her role and abilities. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 9 The proprietor writes a monthly report on the conduct of the home. These reports could be improved by including more detail to show how the home is being managed. It is recommended that periodically a copy of such reports be sent to the CSCI for information. The Home has a quality assurance system. This could be improved as discussed by using the KLORA (Key Lines of Regulatory Assessment) document as a guide for auditing different areas of care and practice in the home. 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.V346164.R01.S.doc Version 5.2 Page 10 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.V346164.R01.S.doc Version 5.2 Page 11 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, 4 and 5. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive the information they require to decide if the home can meet their needs. EVIDENCE: The home had a very detailed Statement of Purpose which contained all the information a prospective guest or their family might need. One relative who completed a survey said they had received good information when making a choice about the home. The Service User Guide had been updated since the new proprietor took over. This document was informative. Two pre admission assessments were examined. The social work assessments were based on immediate needs and did not give any indication of the personality, and cultural background and history of each person to enable the home to know if they could meet each person’s overall needs. This was
Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 12 redressed by the home’s own assessment. The completed paperwork showed where the assessment had taken place and the information indicated the staff member completing the form had taken a genuine interest in finding out about the background, interests and skills of the person being assessed. Either the person or their family had the opportunity to spend some time in the home and the outcome of such visits was recorded. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. Communication within the home was good ensuring the needs of people living in the home are met. The health and personal care needs of people living in the home are met and dignity and privacy is respected. EVIDENCE: Three care files were examined. Each included good background histories to help the staff understand the personalities and needs of the people they were caring for. The files were consistent in layout making information easy to find. Risk assessments had been completed and detailed care plans were in place to guide staff on the care required. A care worker said that staff regularly read the care plans and were informed of any changes at shift handover meetings. There were clear records of GP and district nurse visits and staff had recorded the progress reports from the nurse. The nurses own notes were held in the home for staff to access.
Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 14 Relatives who completed surveys said they were always informed about any changes/incidents and felt that the staff provided the care agreed in the care plan. A Community psychiatric nurse was at the home on the day of the inspection visit to re assess two people about whom staff had concerns. As she was new to the home she was unable to comment on the standard of care or the use of care plans for managing challenging behaviour. Staff responsible for medication undertake a distance learning course, receive training from the manager and have annual updates from the pharmacist. A senior care worker explained the medication system, which is pre dispensed. Systems were in place for checking and recording the medication received. The home had recently written to the pharmacy provider, as they were not receiving the service agreed and leading to staff working extra hours to check the medication. Medication records included a photograph of each person and clear guidance on any special requirements. Those records seen were up to date. Controlled drugs were securely kept and recorded with a system of checks between each shift and when medication was given. A recent medication error where medication had been given to the wrong person had been handled appropriately and the GP, CSCI and family informed. Further medication training has been arranged for the member of staff involved. The people living in the home were neatly dressed in well cared for clothing. The hairdresser was attending to several ladies in one of the lounges. Staff were observed to be discreet when helping people with intimate personal care and were seen to knock on bedroom doors before entering. A small lounge is available for visitors to talk in private as well as using peoples’ bedrooms. A relative suggested that the provision of a cordless phone would make it easier for people to keep in touch with their families and friends. There were no visitors on the day of the visit. Sandfield House DS0000069132.V346164.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported to make choices about day-today matters. Social and recreational activities could be more person centred with the development of a care plan to cover this aspect of care. Menus meet the cultural and nutritional needs of the people in the home. EVIDENCE: The activities coordinator, who is also responsible for administration, is new to the role and described activities such as the motivation people, who visit fortnightly, the popularity of dominoes and the famous faces reminiscence materials used to prompt discussion. Some people had enjoyed an indoor gardening session. The results were pots of flowers outside the home One person attends a local weekly ‘dementia café for people with dementia and their carers and a member of staff said that one person joins the weekly walks for older people organised from the local GP surgery. The manager said staff spend one to one time with individuals either talking or providing human contact.
Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 16 A relative felt there could be a more proactive approach towards sitting together people who could communicate with each other. There were no obvious activities other than the hairdresser on the day of the visit though this provided social stimulation for those people sitting in the same lounge. Overall staff were observed to be pleasant, talking to people and involving them in conversations. One person however would benefit from dementia training as she was overheard telling a person to ‘concentrate,’ indicating a lack of understanding of the illness. People have to rely on the availability of staff to go outside. The large garden is well tended but does not offer a secure area for people to walk freely in and out of the building. One person was saying she found the room airless and would like some fresh air. There could be more focus on care planning specifically for person centred activities with more use of materials produced by companies, which specialise in activity ideas for older people. Organisations such as the ‘pat a pet’ scheme provide stimulation for people who like animals. It is recommended that the activity coordinator develop a prompt file of ideas for staff to use with different people. This could include simple domestic tasks, walks in the garden, reading and discussing the daily newspaper together, creating collages from cut out pictures significant to each person. Each file included a list of any daily activity and the person’s response. This had not been completed with any regularity possibly because staff were not recognising the low-key activities, which take place. The menu included two choices at lunchtime and a substantial tea. Provision was made for special diets. The kitchen had been redecorated, was clean and fridge freezers well stocked. Food temperatures were recorded and a list of peoples’ birthdays ensured that such special occasions were celebrated. The home had attended to recommendations made by the environmental health officer. The cook said that the proprietor allowed her to purchase any food specially requested by people who lived in the home. She had day-to-day contact with people so was able to observe likes and dislikes. Care plans included nutritional assessments and there were records to show weight was monitored. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 17 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were made aware of and protected by the complaints procedure. However all staff require training to understand the protection of vulnerable adults and ensure people in the home are protected. EVIDENCE: The returned surveys showed that relatives are made aware of the complaints procedure. The complaints log had not been completed, as there had been no complaints. However, during the writing of this report an anonymous complaint regarding a member of staff was received. This has been sent to the proprietor for investigation and referred to the adult protection team. The manager said any concerns are dealt with immediately before developing into a complaint. She was advised in future to record how she had dealt with any concerns. The manager and a senior care worker have completed the ‘train the trainer’ course on adult protection but staff have not yet received training. Dates are being arranged to pass the training on to staff. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 18 Age concern advocates have been used in the past to ensure people’s rights were protected. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 19 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, 20,22, 23, 24, 25 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a clean comfortable environment with ongoing maintenance work to keep the home in good repair. Some work has been done to make the home more suitable for people with dementia so that they can retain a degree of independence. EVIDENCE: The new proprietor has carried out a significant amount of maintenance work to improve the environment. The boiler and heating systems have been upgraded, leaking gutters replaced, additional lighting put in one of the corridors, the kitchen redecorated, communal areas throughout the home have been redecorated, with door architraves painted in different colours to help people living in the home to identify their own rooms more easily. The manager said this was already proving effective. The outside paved area was
Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 20 being repaired and levelled on the day of the visit. This area, if made secure and decorated with items which provide sensory stimulation could provide a pleasant outdoor sitting area for people who live in the home. Pots planted with flowers by people in the home provided some decoration to the front entrance. Toilets were well signed and further signs were to be placed around the home to aid orientation. Large calendars were up to date and clocks accurate. A mirror placed on the outside door acted as a diversion for people who would be unsafe if they left the home. All such innovative ideas are good practice and to be encouraged. Redecoration is ongoing and being done at a time to cause least disruption to the people living in the home. This will be followed by the replacement of the rather shabby carpets. The level of lighting in some of the toilets and corridor areas was not suitable for people with poor eyesight and cognitive abilities. The proprietor acknowledged this and said he would improve the lighting. He was also receptive to other suggestions to make the environment more stimulating for the people who lived there. The home has several small lounges, one that can be used by visitors who may wish to have some privacy. Other than the odour of perm solution there were no unpleasant odours detected in any of the areas of the home seen. The staff were to be congratulated as without good cleaning practices odours could build up in the internal corridors which had no natural ventilation. Bedrooms were locked but it was evident that anyone who wished to use their room during the day could do so. Some were very spacious with French doors onto balconies. Unfortunately there was little ventilation in the rooms without opening the doors. This could be a problem to the occupants during hot weather. The laundry was clean and hygienic with systems in place for the control of infection Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 21 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels did not always ensure the well being of the people who live in the home. People living in the home are protected by the home’s recruitment procedures and there is a staff training programme to give staff the knowledge and skills to meet their needs. EVIDENCE: Each member of staff is allocated a group of residents for whom they are responsible on each shift. The manager includes herself in this system, delegating responsibility for the shift to another senior. This enables her to observe practice and understand each persons needs. The accident audit showed there had been occasions when there had been staff shortages. Vacancies were being covered by existing staff working additional shifts. The home was in the process of recruiting more staff. The recruitment and selection file was examined for one member of staff. The file contained a photograph and was neatly sectioned making information easy
Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 22 to find. There was evidence to show that a Criminal Record Bureau check had been done before employment and references obtained. There was a written explanation to show why one referee, who was a family member, had been used. An interview checklist had been completed but the documentation showed that only one person carried out the interview. The employee confirmed this. A person who had changed role within the home had not been interviewed for the different post. If staff change role this should also be subject to application and interview otherwise the home is open to challenges that people do not have equality of opportunity. The manager said she had had overseas applicants for posts who were not entitled to work in this country. She now advertises through the job centre and checks out documentation with the immigration office to ensure only suitable people are employed in the home. Induction training records were completed and signed. Three staff spoken with described the training they had received, which included medication, health and safety, moving and handling, nutrition, fire safety and dementia care. The manager had just introduced dementia training on a DVD for ancillary staff. Several people were doing the palliative care course. Staff had not had adult protection training. 13 staff have NVQ level 2 or above in care and 4 were working towards the award. Relatives completing the survey said they felt staff ‘usually’ had the skills and knowledge to meet the needs of people living in the home Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 23 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, 32, 35, 36, 37 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a competent management team who have the support of the proprietor. The interests and safety of the people living in the home are seen as important to the manager and staff. EVIDENCE: The manager, who has a nursing background, has worked in the home for many years and has a good rapport with the people living in the home. She is supported by a deputy manager with NVQ’s at level 2 and 3 and a diploma in management. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 24 The manager does not have any specialist training in dementia care. It is 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 manager delegates different responsibilities to senior staff in the home and has a system of shift handover meetings, which keep people informed about any changes. Staff meetings are held infrequently, the last one being to introduce the new provider. Matters discussed included personal care, medication, pay and sickness. A newsletter is another way in which staff are kept informed. The deputy manager explained the staff supervision system which aims to take place two monthly. A care worker said she found these ‘appraisals’ a good way of improving her practice. The home does not hold any money but keeps records and receipts for any purchases on behalf of residents, which are then invoiced to families or representatives. All the records seen were neat and orderly. The proprietor writes a monthly report on the conduct of the home. These reports could be improved by including more detail to show how the home is being managed. It is recommended that periodically a copy of such reports be sent to the CSCI for information. The quality audit involves survey questionnaires being sent to other professionals, and families. A report of the outcome of these was seen. The quality assurance system could be improved as discussed by using the KLORA (Key Lines of Regulatory Assessment) document as a guide for auditing practices and procedures in the home. The manager carries out weekly checks on the fire alarm system and the deputy holds monthly fire drills. Accidents are audited and assessments are carried out on equipment in the home. The 5 yearly check of the Electric wiring was done earlier this year and a certificate issued. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 25 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 2 x 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x 3 3 3 3 Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP 16 Regulation 22 Requirement Timescale for action 31/08/07 2 3 OP 18 OP 20 13 13,23 4 OP 27 18 The complaints log must be used to record any complaints and show how they have been handled All staff must receive training on 30/10/07 adult protection. The outdoor areas must be made 31/12/07 safe and secure to reduce restrictions placed on peoples’ movement outside the home. Staffing levels must be 31/08/07 consistent and sufficient at all times to meet the needs of people living in the home 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 Refer to Standard OP 1 OP 7 Good Practice Recommendations The service user guide should be in a format suited to the people it is intended to inform There should be a social and recreational care plan so that activities can be more person focussed.
DS0000069132.V346164.R01.S.doc Version 5.2 Page 27 Sandfield House 3 4 5 6 7 8 9 OP 13 OP 22 OP 25 OP 25 OP 29 OP 31 OP26 10 OP 33 The activities programme should be broadened to include routine daily tasks and give more people opportunities to do things outside the home. Eye catching and stimulating pictures and objects should be placed around the home to act as orientation aids for people living in the home. The lighting levels in some parts of the home should be improved. The proprietor should look at a solution to improving the natural ventilation in those bedrooms with French doors. The interview process should be improved to meet the home’s commitment to equal opportunities. The manager should consider undertaking specialist training in the care of people with dementia in order to keep up to date with current good practice. The proprietor should include more detail in his monthly reports to show how the home is being conducted. Periodically a copy of such reports should be sent to the CSCI The KLORA document should be used as a guide for auditing how the home is meeting the National Minimum Standards for care homes. Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Sandfield House DS0000069132.V346164.R01.S.doc Version 5.2 Page 29 - 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!
