Inspection on 29/04/08 for Sandhall Park Care Home

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate 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

Sandhall Park Care Home 04/07/07

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Sandhall Park Care Home Sandhall Drive Fairfields Goole DN14 5HY Lead Inspector Eileen Engelmann Key Unannounced Inspection 29th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sandhall Park Care Home DS0000070008.V363054.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. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandhall Park Care Home Address Sandhall Drive Fairfields Goole DN14 5HY 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) 01405 765132 01405 765133 sandhall@mimosahealthcare.org.uk None Mimosa Healthcare (No4) Limited Manager post vacant Care Home 50 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (50), Physical disability (50) of places Sandhall Park Care Home DS0000070008.V363054.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP Dementia - code DE Physical Disability - Code PD The maximum number of service users who can be accommodated is: 50 4th July 2007 2. Date of last inspection Brief Description of the Service: Sandhall Park Nursing and Residential Home is situated on a residential estate on the outskirts of Goole. The home is registered to provide residential and nursing care for older people including those with dementia and/or physical disabilities. The home is a purpose built building with enclosed well-kept garden areas for people who use the service. All rooms are on ground floor level. Mimosa Healthcare Limited has produced a welcome pack which people are given before they are admitted to the home. This includes a service user guide, which explains what the home provides. Information given by the manager during this visit indicates the home charges fees from £300.00 to £589.38 per week. The level of fee is dependent on the type of care required and the source of funding. There is a weekly third party top up charge of £25.00. People will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. Sandhall Park Care Home DS0000070008.V363054.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 1 stars. This means that the people who use this service experience adequate quality outcomes. Information has been gathered from a number of different sources over the past 10 months, this has been analysed and used with information from this visit to reach the outcomes of this report. The home is without a registered manager at the present time; during this visit the area support manager was available to give the inspector the necessary information and documentation asked for. For the purposes of this report the area support manager is referred to as ‘the manager’ throughout the text. This unannounced visit was carried out with the manager, staff, relatives and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with people living in the home, relatives and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home and staff. Their written response to these was adequate. We received 1 back from relatives (7 ), 6 from staff (40 ) and 6 from people using the service (40 ). The manager completed an Annual Quality Assurance Assessment and returned this to the Commission within the given timescale. Since the home was visited in July 2007 there has been one formal complaint made to us around use of an unsuitable chair within the home. The provider investigated this and a new alternative chair was purchased for a user of the service. Since the last visit in July 2007 there have been four safeguarding of adults referrals made to the East Riding of Yorkshire Adult Care Management Team. Two allegations were regarding verbal and physical abuse of people using the service. These were fully investigated by the safeguarding of adults team and could not be substantiated, and the home followed through the investigations with disciplinary action were required. One allegation related to security within the home and staffing levels. The local authority team investigated the security issues and these were not substantiated. The staffing rotas showed sufficient staff were on duty. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 6 One allegation related to poor care within the home. The local authority team investigated the issues raised and a number of poor care practises were found. The home produced an action plan to show how it would address the problems and ensure care practises improved. The progress made will be checked during this visit. Safeguarding issues and outcomes areas such as health care, staff supervision, staff training, complaints and safeguarding of adults have been looked at as part of this visit. What the service does well: What has improved since the last inspection? What they could do better: People working in the home must make sure the information in the care plans shows the life history of those coming into the home, so activities and the care to be given reflects the needs, interests and likes or dislikes of each person using the service. The care plans must be reviewed and updated on a monthly basis and show any changes to care. The people working in the home should be talking to the people using the service to find out what they like and how they want to be looked after. This helps the people to have choice in how they are cared for and helps them stay as independent as possible. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 7 People working in the home must make sure that the way they record and give out medication gets better. This will make sure that the health and welfare of the people who live in the home is protected. People who are working in the home have to be given training around keeping people safe from harm, this helps them understand how to look after individuals and speak up if they think anything is wrong. People who are working in the home have to attend more training around safe working practices to make sure they look after their health and safety and that of the people living in the home. The person who owns the home must make sure there are enough staff on duty at all times (day and night) to meet the needs of the people using the service. People working in the home need to continue to go to different training sessions, which will help them understand more about the different needs of the people using the service. This will make the service better as people working in the home become more confident in what they do and how they do things. The person who owns the home must make sure that the service is looked at on a regular basis to see if it is meeting the needs of the people using it, is working within the guidelines of good practice and is looking after the wellbeing of the people living in the home and the people who work there. We would like to thank everyone who completed a survey or spoke to us during this visit. Your comments are very important to us and ensure this report includes the views of people who use the service or work within it. 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. Sandhall Park Care Home DS0000070008.V363054.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 Sandhall Park Care Home DS0000070008.V363054.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): 3, 4, and 6. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff training is not robust and does not ensure that staff have the necessary specialist skills and abilities to meet the needs of people coming into the home. EVIDENCE: Information from the surveys shows that the majority of people received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. Each person has their own individual file and four of those looked at had a need assessment completed by the funding authority or the home before a placement is offered to the person. On the day of this visit a qualified nurse was going out to assess a prospective client. The manager told us that only the nurses, or the senior care staff from the residential unit, go out to assess people and all individuals have received training in how to complete the assessment paperwork. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 10 The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person and their family. One care plan we checked was for a fairly recent admission, but this was not written until 3 weeks after the person had come into the home. This is not acceptable practise and the area support manager assured us that she would talk to staff about ensuring the plans are in place within 5 days of admission. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Discussion with four people showed that they were satisfied with the care they receive and have a good relationship with the staff. Information from the training files and training matrix indicates that the uptake of staff training during 2007 was poor and the majority of staff require updates for their basic mandatory safe working practice training. The manager has had input into the home from January 2008 and her influence is clear in that staff are now attending training and more is booked for 2008. A number of people using the service have conditions relating to dementia, diabetes, heart disease, depression, strokes, arthritis and other problems linked to old age. The staff do have access to a range of more specialised subjects that link to the needs of people using the service, although few have attended training sessions in 2007. One allegation made in 2008 was in relation to poor care practises. Checks at this visit showed that action has been taken by the home to improve the areas of care highlighted in the investigation and this includes staff record keeping. Discussion with the manager indicated the company has recognised the need to improve the specialist training within the home and is planning more comprehensive dementia training for the staff to give them a good, clear understanding of dementia, what the different types of dementia are, how they affect people and how they can help people with dementia. The staff training matrix shows that eight people are booked to attend a distance learning course in May 2008. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that the majority of the people are of white/British nationality, and there are a number of people with different faiths and religions. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of people in the home. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 11 Checks of the staffing rotas and observation of the service showed that the home employs four staff from different countries and cultures. People using the service are unable to make a choice of staff gender when deciding whom they would like to deliver their care, as the home has no male care staff due to a lack of suitable applicants. The manager said that she would discuss this with people wanting to use the service during the assessment process. The home does not have any intermediate care beds and therefore standard six does not apply to this service. Sandhall Park Care Home DS0000070008.V363054.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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the staff performance around recording within the care plans and medication system must be made, to ensure the peoples’ health and welfare are protected. EVIDENCE: At the last visit in July 2007 a requirement was made that ‘The registered person must ensure that the service users plan of care is regularly updated and that there is evidence of regular monitoring and system in place to identify any deterioration in the service users mental health’. Checks at this visit found that this was partly met and therefore the requirement will remain on this report. The care of four people was looked at in depth during this visit and included checking of their personal care plans. Outcomes of the investigation by the adult protection team into a safe guarding allegation made in 2008 (poor care practises) were also checked during this visit. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 13 The care plan format used by the home is detailed and comprehensive, but because staff are not always completing the information required, and not including dates and signatures of the person writing the plan, this dilutes the quality of the finished care plan. All of the care plans looked at during this visit showed a lack of monitoring and evaluation of care from September 2007 to January/February 2008. This is not acceptable practise and the issue was discussed with the manager. Equality and diversity information about people is not clear on the care plan format. We found that information about religious beliefs, sexuality, ethnicity and people’s preferences regarding staff gender for personal care was not included in all plans. Changes to people’s care and the actions needed by staff to meet their changed needs are not always reflected in the care plan. Instead information is put into the daily notes or jotted onto additional paperwork in the plan. There is a yearly formal review process for the care of people using the service with the funding authorities and family (where the person receiving care consents to this). However checks of the care plans indicate this may not be up to date and the formal review process should be extended to include people who fund their own care. Positive aspects of the plans include risk assessments for moving and handling, nutrition, pressure sore development, falls and individual choices regarding activities of daily living. Weights are recorded monthly, although there is a gap between September 2007 and January/February 2008, and evidence that staff are contacting outside health professionals for advice and visits were needed. Since the manager came to the home in January 2008 the plans have shown improvement, but not enough to demonstrate a consistent approach by the staff. Information from the surveys indicates that the people who responded are satisfied that the staff give appropriate support and care to those living in the home. People spoken to said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. One relative commented that ‘ the staff contact me if my relative has a fall or becomes ill, they get the doctor out when needed and keep me informed’. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 14 people and relatives indicate that on the whole they are satisfied with the level of medical support given to the people living at the home. Checks of the medication show the home is using Boots the Chemist as their pharmacy supplier and their MDS system of medication is in use. Observation of the medication records show that there are some areas of practice that need to improve and these include: • • • There are a number of missing signatures where staff who have given out medication have not signed on the record sheet. Not all medication has been signed into the medication record sheet and this makes auditing supplies difficult. Where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. Checks of the controlled drug stocks and the register show that these are up to date and correct. Fridge medication is in date and stored correctly. At the last visit in July 2007 a requirement was made that ‘The registered person must ensure that any medication training received by the staff is accredited’. Checks at this visit found it has not been met and therefore it will remain on this report. Checks of the staffing matrix shows that no member of staff has undergone accredited medication training since the last visit in July 2007. Discussion with the staff indicated they have all received training on the new MDS medication system in the past year, but this is not the same thing as accredited training. The manager said she is talking to the registered person about providing suitable training and hopes to implement this within the next year. People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. Sandhall Park Care Home DS0000070008.V363054.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. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home employs an activities organiser for 30 hours a week and she works Mondays to Fridays from 9.30am to 3.30pm. Discussion with this individual showed that she is changing the way activities are being delivered. People are being encouraged to mix with each other throughout the home, using the different lounges for coffee mornings and group activities. People who cannot attend group sessions or prefer to spend time in their rooms are able to take part in 1-1 activities that reflect their interests and hobbies. Information about the weekly programme of events and forthcoming attractions is on display in the entrance hall of the home. The activity coordinator has begun a quarterly newsletter that details this information and includes, quizzes, poems and other items of interest for those living in the home. The newsletter is available to anyone expressing an interest. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 16 Outside entertainers are booked twice a month and in April there were two different singers who came into the home and for May there is a ‘clothing party’ and a country and western singer booked. The mobile library visits every 6 weeks and the home has a stock of large print and ‘talking books’ for those who have difficulty reading. Discussion with three people in the home indicates they can take part in a variety of daily events including bingo, crosswords and arts and crafts. One person said she particularly likes going out with her family, and that she keeps herself busy with quizzes, word searches, television, bingo and chatting to others living in the home. Records are kept of all the social interactions going on in the home and evidence seen at this visit indicates that people are encouraged to celebrate Christian events such as Birthdays, Easter and Christmas. People have access to the local churches and weekly visits by the Church of England minister and Catholic priest are arranged on an individual basis. Meetings for people using the service and their relatives are held every month; these are used as an opportunity for individuals to express their ideas of what activities they want and to give their feedback on events that have taken place. The manager, cook, housekeeper and maintenance man also attend the meetings so other issues regarding the home and life within it can be discussed and changes made where necessary. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the town. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. One person who spoke to us was full of praise for the activity organiser and the administrator of the home. They said ‘ if I have any problems they will sort things out for me, I know that my relative is in good hands’. Three other people said ‘ they treat you as part of a family here’, ‘the staff are very friendly and are good at letting you know if there are any concerns about the health of our relatives’. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. There is some information and advice on advocacy and this is on display in the entrance hall. The manager said she has attended training on the Mental Capacity Act, but there is no evidence that staff have received training around current legislation in equality, diversity and disability matters. The registered person should make sure that staff have sufficient knowledge about human rights legislation, so they understand individual rights within the care home and out in the community. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 17 The home has two dining rooms and offers people a choice of eating facilities. One dining room has more people requiring assistance with eating and drinking than the other, and staff were seen to be sat helping individuals with their lunch time meal. One person told us ‘the meals are very good, I have put on weight since coming into the home and I am well looked after’. Another two individuals expressed some dissatisfaction with the meals saying ‘we don’t always like what is on the menu, we can have different things but the quality of the meals is not always good’. Observation of the lunchtime meal showed that there were at least four different options of meals given out to people, including soft diets and those for diabetics. Presentation of the meal was acceptable and specialist cutlery and plate guards were available. No menus were seen on display although a laminated copy was found on a cabinet in one dining room. People told us the staff took round a tea list and they could choose their meal options, but few could remember what they had ordered for lunch. Sandhall Park Care Home DS0000070008.V363054.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with some evidence that peoples’ views are listened to and acted upon. EVIDENCE: Checks of the records in the home showed that there have been two formal complaints made to the service since the last inspection. The manager has investigated each problem and taken appropriate action to resolve the matters. The written responses to the complainants are kept on file. The Commission for Social Care Inspection has received one formal complaint about the service since the last visit in July 2007. This was passed to the registered person to investigate and was resolved by their actions. People who spoke to us have a clear understanding about how to make their views and opinions heard and three people said ‘I have had no reason to complain, but staff would listen to me and take action if needed’. Relatives told us they are aware of the complaints procedure and are confident of using it if needed. Four safeguarding of adults allegations (abuse) have been made since the last visit to the home. The local funding authority (social services) team have investigated the allegations: Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 19 Two allegations were regarding verbal and physical abuse of people using the service. These were fully investigated by the safeguarding of adults team and could not be substantiated. One allegation related to security within the home and staffing levels. The local authority team investigated the security/staffing issues and these were not substantiated. One allegation related to poor care within the home. The team investigated the issues raised and a number of poor care practises were found. The home produced an action plan to show how it would address the problems and ensure care practises improved. Following the investigations the authorities and the home have taken appropriate action to ensure the safety of the people living in the home is protected and promoted. Safeguarding issues and outcomes areas such as health care, staff supervision, staff training, complaints and safeguarding of adults have been looked at as part of this visit. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. There is an ongoing training programme for staff to attend safeguarding of adults awareness training, but a number of longstanding staff (57 ) require refresher training in this area of care as they last attended in 2006. The registered person must also seek training for staff around dementia care and challenging behaviours so staff have the skills and knowledge to recognise and meet the needs of the people living in the home. This was a requirement made in the last report (July 2007). This was discussed with the manager who said she is taking this matter up with the company who is now providing their training. Sandhall Park Care Home DS0000070008.V363054.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, 22 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within this home is good, providing people with a comfortable and homely place to live. EVIDENCE: The home has an ongoing maintenance and refurbishment programme and the manager was able to show us work that has been completed since the last visit in July 2007 and discuss work that is planned for the next year. At the moment the home does not have its own maintenance man, but is able to access this service from another home in York. It is not an ideal situation and recruitment is ongoing for the post. Walking around the home, it was found that the environment is clean and comfortable. One area that does require some attention is the back corridor off room 12 in the nursing unit. We found that paperwork for storage/filing is being kept in Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 21 boxes in the corridor. This is not acceptable practise as this could be a fire hazard and is certainly not in line with confidentiality policies for the home. This matter was discussed with the manager. People were seen to be using the four lounges and two dining rooms during this visit and observation of the communal areas found these to be warm, bright and odour free. People living in the home have access to two internal courtyards, which provide secure areas to sit in. These have paved areas and planted sections and have a variety of seats and tables for people’s use in the warmer weather. Some individuals have birdbaths and feeders outside of their bedroom windows to watch the wildlife. Inspection of the home showed that it has been designed and built to meet the needs of disabled individuals. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious and have enough room for people in wheelchairs or with walking frames to pass by comfortably. The home is single storey and has flat walkways inside and out, providing safe and secure footing for people with limited mobility. Discussion with the staff and manager indicates that there is a wide range of equipment provided to help with the moving and handling of the residents and to encourage their independence within the home. This includes mobile hoists, bath hoists, stand aids and handrails. There are a number of specialist nursing beds provided, to aid staff in caring for the people using the service and make life more comfortable for individuals who spend a lot of time in bed. Bed rails are used in some rooms where individuals have been perceived as being at risk of falling out of bed. The staff and the maintenance man do checks of the rails weekly to ensure they are fitted correctly and in working order, and risk assessments are signed by the person or their family and kept in the individual’s care plan. We observed that on this visit all bed rails were in the down position whilst people were out of bed and bumpers are available to cushion the rails when in use. At the last visit in July 2007 a requirement was made that ‘a plan must be put into place to address the inadequacies of the call bell system, so that service users can be satisfied that they are able to attract the attention of staff in a dignified way’. This is an outstanding requirement from previous reports and is not met at this visit. It will remain on this report. Observations during this visit showed that the front door bell and the nurse call system exhibit extremely loud and persistent noise. Discussion with two people and their families indicated they had to move rooms to get away from the noise levels and achieve some type of peace and quiet. It was clear that Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 22 the systems in use interfere with the quality of life for these individuals and the registered person must take action to improve the call functions. Discussions during this visit indicate that people using the service find the home to be spotlessly clean and are satisfied with the laundry service provided by the home. A recent outbreak of a diarrhoea and vomiting bug did mean the home closed to visitors for a while, until the infection was cleared up. Staff told us that there is an ample supply of aprons and gloves for personal protection whilst carrying out care duties and they were provided with antiseptic hand cleanser. Domestic staff had an intensive cleaning regime in place to ensure all possible measures were taken to resolve the situation. Infection control policies and procedures are in place, but only 3 out of 49 staff (6 ) have attended training in this area of care in the past year. The registered person must make sure this aspect of staff training is promoted and more staff are given the opportunity to attend appropriate courses. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 23 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. We have made this judgement using a range of evidence, including a visit to this service. Staff training and development are inadequate and do not promote or protect the health, safety and well being of those people using the service. EVIDENCE: Comments from the relatives and people using the service indicate that the home is extremely busy at times and individuals may wait for attention at peak times, but the friendly attitude of the staff and their willingness to help make up for this. At the time of this visit there were 39 people in residence (15 with nursing needs and 24 with personal care needs) and the staffing rota showed that the following staffing levels are in use 7.15am to 2.30pm – 1 nurse and 4 care staff on duty 2.30pm to 9.15pm – 1 nurse and 3 care staff on duty 9.15pm to 7.15am – 1 nurse and 3 care staff on duty Discussion with the manager indicates the numbers of staff have been reduced recently due to the current bed vacancies, but will increase as more people come into the service. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 24 Information from the manager at this visit, about the number of care staffing hours provided (722), and the dependency levels of the people using the home, was used with the Residential Staffing Forum Guidance and showed that the home is running at levels below the recommended guidance (807). The manager and registered person must make sure the dependency levels are checked regularly and sufficient staff are on duty at all times. Comments, from the people using the service and their relatives, are very positive about the staff. Individuals said ‘ the staff are friendly, approachable and welcoming’. Everyone felt their care needs were being met and that there was no undue waiting for attention. Over the past year 14 staff have left the company, but there remains a solid core of long-term employees (45 ) who have worked in the home for between 5–10 years. The lack of a permanent manager in the last few months has impacted on the staff. Uptake of training has not been promoted or monitored effectively until 2008, staff supervision lapsed and staff have not been proactive in maintaining the standards of record keeping without the guidance of a manager. Since the present manager has been in place, improvements to staff practises have been seen by us, but the timescale is too short to say if these can be sustained. They will be checked at the next inspection. At the last visit in July 2007 a requirement was made that ‘The registered person must ensure that the staff have received training in dementia and how to handle any challenging behaviour’. Checks at this visit show that work is in hand to achieve this requirement, but it has not been met at the moment. It will remain on this report. There is an induction course for new members of staff, and 57 of the care staff have achieved an NVQ 2 or 3, with 8 working towards this award. The home provides a mandatory staff-training programme and this includes some more specialised training to help staff develop their skills and knowledge around pressure care, dementia awareness and continence promotion. Information from the staff training files and training matrix indicates that the majority of the staff require updates with their basic fire safety training (80 ), food hygiene (63 ), medication (60 ), moving and handling (88 ) and COSHH safe working practice training (100 ), health and safety (82 ), safe guarding of adults (57 ) and infection control (94 ). There is a matrix in place, which identifies what training has been achieved by the staff. Staff- training files hold the certificates of achievement but staff do not have their own personal training plans in place, showing each person what training they must attend each year. The manager must ensure these are developed and discussed with staff during supervision. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 25 Discussion with the manager indicates she has plans in place to book additional training sessions for staff and the company is working on introducing a more robust training programme for dementia care. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. The home employs two individuals who are under the age of 18, both are on apprenticeships and their job descriptions identify that they do not undertake personal care tasks. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 26 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, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems within the home are not robust and must be improved to ensure the health, safety and welfare of the people who live in the home and staff are maintained and protected. EVIDENCE: The home does not have a registered manager in place. This was a requirement in the last report (July 2007) and has not been met. At the moment the area support manager is visiting 2-3 times a week and the deputy manager is providing cover at other times. The registered person is actively recruiting for a permanent manager and interviews are taking place. We have commented throughout this report that the lack of a registered manager, especially prior to the area support manager being in place, has Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 27 impacted on the quality of care, record keeping and overall standards of the home. Improvements are now taking place, and the area support manager is working extremely hard to move the service forward. We recognise the efforts of the deputy manager and the administrator, who have offered help and support to the staff during the past six months. The home has an up to date quality award from Investors in People and is working towards achieving the local councils quality award (QDS) part one. Meetings for people using the service and their families/friends are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. People and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The manager and senior staff complete in-house audits of the home and its service on a monthly basis, and the registered individual does spot checks and completes the regulation 26 visits. Feedback is sought from the people using the service and relatives through regular meetings and satisfaction questionnaires. This information must be analysed and put together into an annual development report as part of this process, to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. Checks of the finance systems within the home found that computerised records are kept for people’s personal allowances; the administrator on a daily basis up dates these. Information from the Annual Quality Assurance Assessment indicates the majority of people have their families looking after their financial affairs, and checks of the system show their relatives top up the person’s individual allowance account on a regular basis. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the administrator or manager has access to the funds. Staff supervision has been patchy over the past six months. Since the manager has been in place this aspect of practice has been re-started, but due to the short time this has been carried out there is no pattern of consistency. This will be looked at during the next visit. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 28 Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and staff are aware that regulation 37 reports must be completed and sent on to the Commission where appropriate. This was a requirement in the last report (July 2007) and has been met. At the time of this visit it was clear that the maintenance man records were not always kept to a high standard, with missing dates and information making it difficult to audit what had been done. The manager is working towards improving this practise and things should get better when a permanent member of staff is recruited to this post. Checks of the fire risk assessment indicated this was last updated in 2005 and must be reviewed as soon as possible. No evidence of generic risk assessments for the home could be found and the registered person must make sure these are completed and reviewed yearly. Staff are able to access safe working practice training although uptake has not always been as good as it should be over the past year. The registered person must make sure all staff attend this training. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 29 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 30 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 OP3 Regulation 15 Requirement The registered person must make sure that each person is provided with a written plan of care for daily living, and longer term outcomes, based on the care management assessment/care plan or the home’s own needs assessment. This must be in place within 5 days of admission. So staff have sufficient information to deliver the care needed for each person and protect the individuals health and welfare. The registered person must make sure that staff, individually and collectively, have the skills and experience to deliver the services and care which the home offers to provide. Timescale for action 01/07/08 2. OP4 12(1) 01/12/08 3. OP7 15 So people can be confident that their needs relating to old age and dementia are recognised and managed appropriately. The registered provider must 01/07/08 make sure that the care plans are detailed and individual to the DS0000070008.V363054.R01.S.doc Version 5.2 Page 31 Sandhall Park Care Home person they are about, putting the person at the centre of it, and giving a picture of who they are as well as what their needs are and how to met them. The plans must be regularly updated and show evidence of regular monitoring and have a system in place to identify any deterioration in a person’s mental health. The plans should meet relevant clinical guidelines produced by professional bodies concerned with the care of older people and those with dementia. This will make sure that staff have access to information that will help them to provide person centred care and support. Given timescale of 30/10/07 was not met. Accurate records must be kept of all medications, received, administered, leaving the home or disposed of to ensure there is no mishandling. The registered provider must make sure that medications in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971. To make sure people receive their medication correctly and their health and safety is not put at risk. The registered person must ensure that any medication training received by the staff is accredited. To make sure staff have the skills and knowledge of how Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 32 4. OP9 17 01/07/08 5. OP9 13(2) 01/12/08 6. OP18 13(6) medicines are used and how to recognise and dealt with problems in use. Given timescale of 30/10/07 was not met The responsible individual must make sure that the staff attend appropriate training in Safeguarding of Adults procedures, management of challenging behaviour and dementia care. To prevent residents from being harmed or suffering abuse or being placed at risk of harm or abuse. A plan must be put into place to address the inadequacies of the call bell system and the front door bell. So that people can be satisfied that they are able to attract the attention of staff in a dignified way, whilst enjoying a peaceful environment. Given timescales of 31/08/06 and 30/10/07 were not met. The registered person must make sure that staff receive appropriate training on the control of spread of infection in accordance with relevant legislation and published professional guidance. So the health and well being of the people using the service is promoted and protected. The registered provider must ensure there are sufficient staffing numbers and skill mix of staff to meet the assessed needs of the people, the size, layout and purpose of the home at all times, and additional staff are on duty at peak times of activity DS0000070008.V363054.R01.S.doc 01/12/08 7. OP22 16, 23 01/12/08 8. OP26 OP38 13(3)(4) (a)-(c) 01/12/08 9. OP27 18 01/07/08 Sandhall Park Care Home Version 5.2 Page 33 during the day. So people can enjoy a good quality of life and be confident that their health and social care needs will be met. The registered person must ensure that there is a training programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the people using the service. Specialist training on the elderly and diseases relating to old age and dementia must be included in the training programme. The registered person must make sure that staff have an individual training and development assessment and profile in place. So the health, safety and welfare of the people in the home is protected and promoted, and staff have the skills and knowledge to provide a high standard of care. Given timescale of 30/11/07 was not met. The registered person must 01/12/08 advertise for and recruit a permanent manager Given timescale of 30/10/07 was not met. 01/04/09 The registered person must make sure there is an annual development plan for the home, based on a systematic cycle of planning-action –review, reflecting the aims and outcomes for people using the service. So people read the information about where the service is going and how the management team is addressing any shortfalls in Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 34 10. OP30 OP38 18 01/12/08 18(1)(c) 11. OP31 8 12. OP33 24 (1)(a)(b) (2)(3) 13. OP36 18(2) the service. The registered person must ensure that staff receive formal supervision at least six times a year. The supervision must cover all aspects of practice, philosophy of care in the home and career development needs. 01/12/08 14. OP38 23(4)(5) So staff can receive feedback from their manager about their personal performance and improve their standard of work. The registered person must 01/07/08 ensure that the fire risk assessment for the home is up to date and that generic risk assessments are completed. 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. Refer to Standard OP7 Good Practice Recommendations The manager should make sure that formal care reviews with the person receiving the service, the funding authority (where applicable) and the persons family or representative are in place and up to date. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), they include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The manager should enable staff to access training around current legislation in equality, diversity and disability matters, to improve the staffs knowledge and understanding of a person’s individual rights within the care home and out in the community. The manager should provide alternative storage arrangements for paperwork currently being stored in a DS0000070008.V363054.R01.S.doc Version 5.2 Page 35 2. OP9 3. OP14 4. OP19 Sandhall Park Care Home 5. OP31 corridor. To ensure confidentiality is maintained and fire risks are minimalised. The registered person should ensure that improvements to the management of staff training and development, staff supervisions and quality record keeping are completed within the given timescales. Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 36 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. Extracts may not be used or reproduced without the express permission of CSCI Sandhall Park Care Home DS0000070008.V363054.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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