CARE HOMES FOR OLDER PEOPLE
Sandhall Park Care Home Sandhall Drive Fairfields Goole DN14 5HY Lead Inspector
George Skinn Unannounced Inspection 4th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sandhall Park Care Home DS0000070008.V345220.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.V345220.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 None Mimosa Healthcare (No4) Limited 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.V345220.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 06/07/06 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 has fifty places for service users with nursing and personal care needs. The home is a purpose built building with enclosed well-kept garden areas for service users. All rooms are on ground floor level. Mimosa Healthcare Limited has produced a welcome pack which service users are given before they are admitted to the home. This includes a service user guide, which explains what the home provides. The monthly fees currently ranges from £249 to £638. Additional charges are made for hairdressing, chiropody and newspapers. There is a weekly third party top up charge of £25.00. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced site visit undertaken over 8 hours, during this time service users were spoken with, relatives were spoken with, staff were interviewed, records were looked at and the building was inspected. No preinspection surveys were sent out prior to the site visit, a selection of these for service users, staff and relatives to complete were left at the home to be sent to the CSCI at a later date. No one who lives at the home are from an ethnic minority, but the home do acknowledge peoples differences and provide flexible services and facilities which cater for diverse individual needs. What the service does well: What has improved since the last inspection? Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 6 The home has made sure that all fire drills are now recorded and these happen on weekly basis. The home have made sure that safety rails used on service users beds during the night to keep them safe are now fitted properly and checked regularly. The home have improved the way they record complaint and this now seeks the views of the complainant and if they are satisfied with the way the complaint was investigated and the findings. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 7 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.V345220.R01.S.doc Version 5.2 Page 8 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): People who use this service experience good quality outcomes in this area. Potential service users receive appropriate information to enable them to make an informed choice. Service user are assessed prior to admission to the home This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence in service users files indicated that they are assessed prior to admission to the home. Placement officers prior to admission assess those service users placed by the local authority and those who are privately funded are assessed by the home. On the day of the site visit a potential service user visited the home and the deputy undertook a pre admission assessment to establish if the home could meet their individual needs. The admission procedure does allow for trial stays and emergency admission are avoided when possible. Service users receive a welcome pack when they are admitted to the home, those service users spoken with could not remember receiving this but knew the home was right for them, one service user said “this home is much better than the one I was in previously and think I will settle well”. People are provided with information prior to admission one relative spoken with
Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 9 confirmed that she had received information before choosing the home for her partner and was able to make an informed choice using the information received. She was aware that home charges a £25 top up fee each week and felt this was money well spent. The home does not admit service users for intermediate care. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 10 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): People who use this service experience good quality outcomes in this area All service users have a plan of care. Some service users ability to make decisions about their lives is limited by their capacity. Service users are protected by the home procedure for handling medication. Service users are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users have a plan of care these contain extensive risk assessments which include dependency levels, risk of falling, nutritional assessments, risk of pressure sores, and emotional well being . The up dating of the files was found to variable with written evidence indicating that some files were updated more regularly than others. Evidence indicated that service users mental health was not reviewed or documented thoroughly enough to indicate any changes or if any therapeutic intervention was required. This was evidenced following a conversation with a service user which indicated that that person’s mental health was compromised. When spoken with the deputy showed awareness of the situation but the service user’s care plan did not indicate that this had been reviewed effectively, or whether there was a system in place to establish if the service users mental health was deteriorating.
Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 11 The service users’ files did not evidence that a “best interest” meeting (where the person, relatives and those involved in meeting their health care needs discuss what is in the person’s best interests) had been held in order to agree constraints on civil liberties. One service user had had access to a mobility aid curtailed to prevent injury to other people– this was documented in the care plan. But the care plan also identified that her physical independence care was dependent on her retaining this aid at all times. There was evidence on the file that service users had been involved where possible with the formulation of their care plans and these had been agreed with the service users. There was also evidence of service user’s relatives or representatives agreeing care on behalf of those service users who were unable to. Relatives spoken with during the site visit confirmed that they are involved with the review process. The service users’ files included evidence that assessments are made about the risk of developing pressure sores. Appropriate equipment is provided and observations made indicated this is used appropriately. The service users’ files evidenced that they can access health care professions when required and have regular contact with their GP. Observation was made during the site visit of the staff administering medication; their handling of medication was seen to be good and they had good practise with regard to the recording of the service users medication. Nursing staff are bound by their code of conduct with the NMC regarding the administration of medication, senior care staff had received training, however no evidence was seen which would indicate that this is accredited. The staff were seen to treat the service users with dignity and respect; observation made during the site visit indicated that any personal tasks were undertaken in private. Staff were seen to be sensitive when helping service users and interaction was respectful. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 12 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): People who use this service experience good quality outcomes in this area. Service users lead a life style which is of their choosing. Service users are enabled to maintain contact with relatives and friends. Service users are provided with a well balanced and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There continues to be an extensive activities program available for the service users. Activities are based on service users interests and appropriate to their needs. The home employs an activities coordinator who undertakes group activities and individual activities. The service users were playing bingo during the afternoon. The staff were observed undertaking activities with the service users these were more for those with complex needs and included talking and making sure they were listening to music of their preference. Staff were seen to talk with the service users appropriately giving them time to answer and not speaking too fast. Those visitors spoken with during the site visit confirmed they were made welcome at any time, one said “they always make you feel welcome no matter what time you come, and they are not funny if you come at meal times” all service users are in single rooms and these are used for privacy if required. Outside entertainment is provided for the service users using local amenities and entertainers come in to the home.
Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 13 Service users confirmed that they could exercise choice around when to get up and when to go to bed, this is also recorded in the service users files; one service user said “I can come and go as I please no one stops me doing anything”. The service users can also exercise choice in their daily lives and have choice of where they like to sit, however they did confirm that they do like to sit with friends. The home provide the service users with a balanced and nutritional diet, they also provide specialist diet for example diabetic and soft diets; there is a four week menu in operation and a choice is offered at both lunch and tea time. Staff were observed to assist the service users who required help with eating with dignity and respect, they allowed the service user to set the pace and did not hurry them. The main meal of the day looked appetising and was well presented, service users confirmed the standard of food was always good comments included “the food is excellent and there is always a good choice” “ I really enjoy the food and it’s always nice and hot”. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 14 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): People who use this service experience good quality outcomes in this area Service users and their relatives know who to complain to and are confident that these complaints will be taken seriously Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to have a comprehensive complaints procedure which is provided as part of the welcome package. Those service users spoken with knew whom to complain to and were confident that this would be dealt with appropriately one service user said he “would see the boss” if he had any complaints. Relatives spoken with were aware of the homes complaints procedure. Staff interviewed were aware of the safeguarding adults procedure and the deputy manager stated they are due to have refresher POVA training within the next month from the companies training department. Complaints are recorded in a log and there is now a record of the level of satisfaction of the complainant with the outcome of the investigation. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 15 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): People who use this service experience good quality outcomes in this area. Service users live in a safe well-maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a single story purpose built building and all areas are easily accessible to service users many were seen manoeuvring themselves around the home. All areas of the home were clean and tidy and free from malodours, there were no hazards left around the home which could hinder the service users mobility. There is an enclosed court yard in the centre of the home and the service users can have easy access to this one service user said “I can do a bit of gardening when I want and I have planted a few plants”. The local environmental health department has visited the home and there were no requirements set. Staff were seen to be using protective clothing and the home has infection control policies and procedures in place to protect the service users. Laundry facilities comply with the relevant legislation and are situated well away form the food preparation area.
Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 16 Following the last key inspection the home were asked to review the call bell provision in the lounge, this has not been addressed. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 17 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): People who use this service experience good quality outcomes in this area. Service users needs are met by the number and skill mix of the staff on duty Service users are in safe hands Service users are protected by the homes recruitment policies and procedures Service users benefit from a well trained staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records seen indicated that the skill mix and numbers of staff are adequate to meet the needs of the service users. Staff files looked at contained evidence that the homes recruitment is robust and protects the service users. There was evidence of Criminal Records Bureau (CRB) checks being undertaken prior to the commencement of employment, there was evidence of references being taken and applications forms completed which covered any gaps in employment. Staff have received mandatory training in manual handling, health and safety, first aid, basic food hygiene and fire. Following the last key inspection the home were required to ensure the staff have received training in dementia and challenging behaviour, evidence gathered during this inspection by interviewing staff and inspection of training records indicate that this is still an outstanding requirement. Staff spoken with displayed knowledge of how to deal with any challenging behaviour but confirmed that this knowledge had been gained from other members of staff rather than any formal training. Over 50 of the staff have gained a qualification to NVQ 2 and NVQ 3. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 18 Service users spoken with during the site visit commented on the quality of the staff comments included “the girls are very good” “they can’t do enough for you they are all very kind”. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 19 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): People who use this service experience adequate quality outcomes in this area. Service user can have an input into the running of the home The home ensures the health and safety of service users and staff where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently without a manager; senior managers are giving support and spend time at the home so they are accessible to the staff. The home has a well-developed quality assurance system in place which consults with service users and all other stakeholders. The findings are published and developmental aims are set for those areas of shortfall. The service users money was not looked at during this site visit as no issues have been raised since the last key inspection and the systems have not changed.
Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 20 Fire drills are held six monthly and the maintenance person tests fire alarms weekly. The home has relevant health and safety policies and procedures in place and these are updated and reviewed on a regular basis notices are displayed around the home. Following the last key inspection there was a requirement to assess all bed rails used, this has been done and systems are in place to ensure these are properly fitted and safe. None were found to be defective during this site visit. There was also an issue raised about the storage of Steradent in service users bedrooms, this has been addressed and the dangers of not storing them appropriately has been discussed with the service users and risk assessment is in place in each of the service users files. There was evidence in the service users files of an incident which should have been reported under the requirements of Regulation 37 of the Care Homes Regulations 2001. Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 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 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 2 Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Timescale for action 30/10/07 2 OP9 13, 18 & 19 16,23 2. OP22 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 The registered person must 30/10/07 ensure that any medication training received by the staff is accredited A plan must be put into place to 30/10/07 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. Outstanding requirement previous time scale not met (31/08/06) new time scale set. The registered person must ensure that the staff have received training in dementia and how to handle any challenging behaviour. The registered person must advertise for and recruit a
DS0000070008.V345220.R01.S.doc 3 OP30 18 & 19 30/11/07 4 OP31 4, 5, 18 & 19 30/10/07 Sandhall Park Care Home Version 5.2 Page 23 5 OP38 permanent manager 10, 12, The registered person must 13, 16, 17 ensure that those incidents & 37 which must be reported to the CSCI by virtue of Regulation 37 of the Care Homes Regulation 2001 are reported 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sandhall Park Care Home DS0000070008.V345220.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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
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