CARE HOMES FOR OLDER PEOPLE
Sandholme Fold Sandholme Crescent Hipperholme Halifax West Yorkshire HX3 8LP Lead Inspector
Cheryl Stovin Unannounced Inspection 25th January 2006 11:00a 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 Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 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. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Sandholme Fold Address Sandholme Crescent Hipperholme Halifax West Yorkshire HX3 8LP 01422 202081 01422 206207 gwen.baxter@anchor.org.uk 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) Anchor Trust Care Home 41 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Old age, not falling within any of places other category (38) Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Sandholme Fold is owned and managed by Anchor Trust and is registered to provide accommodation and care for up to forty one older people. The establishment is purpose built and is situated in a residential area in the Hipperholme district of Halifax, with easy access by public transport to the town centre. The centre of Hipperholme with its shops and community facilities is nearby. The accommodation comprises of forty individual bed-sitting rooms, all equipped with an en-suite toilet and washbasin, and a kitchenette area with a fridge. The rooms are unfurnished and service users are encouraged to furnish and equip the rooms with their own furnishings and to their own taste. This in turn aids orientation and independence. In addition to the private accommodation communal areas are provided which are spacious and comfortable and provide the venue for a wide range of social activities to take place. The establishment is well maintained throughout with a routine programme of refurbishment. Well maintained and safe and accessible garden areas are provided with ample car parking facilities for staff and visitors. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 25th January 2006. Over an inspection year from April until March, care homes have a minimum of two inspections a year. The last inspection was also unannounced and took place on 1st August 2005. During the course of this inspection several service users were consulted as to their views of the standard of care and facilities provided within Sandholme Fold, and all spoke very highly of the service provided. One resident stated that it was “a superb place to live”, with another describing the home as “excellent”. No requirements of recommendations were made as a result of this inspection. What the service does well:
The home is staffed by a well trained and motivated workforce committed to providing a high standard of care and attention to the service users. Service users choice and preferences regarding routines of daily living are assessed on admission and flexible packages of care are arranged to ensure that service users experience their preferred choice of lifestyle. An activities co-ordinator is employed, and works flexibly to enable a range of activities to take place at different times of the day and week, the activities on offer are impressive, and include bingo: quizzes, bowls, skittles, word games, golf, discussion groups, chair exercises, music, and visiting entertainers. The inspector was invited to join in a discussion group which was being held during the inspection, the group was lively with a wide range of issues discussed. In addition to the organised activities impromptu outings are also arranged. Service users are also encouraged and enabled to follow their own interests and hobbies. Regular religious services are held within the establishment enabling service users to fulfil their spiritual needs. Anchor homes has a’ pets policy’ which enables service users to bring with them much loved well behaved pets. Details of the policy and the service users rights and responsibilities regarding pet ownership are detailed in the licence agreement. The service users private accommodation consists of 41 individual bed-sitting rooms all equipped with a kitchenette area and en-suite facilities. The rooms are unfurnished, apart from carpeting, and unless there is a reason why it is not possible, service users are expected to furnish and equip the rooms with their own possessions. This results in each of the bed-sitting rooms being highly personalised which truly reflects the individuals own tastes and
Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 6 interests. This is in turn aids orientation and independence. Service users hold the key to their own front door, which is equipped with a door bell and a letter box. What has improved since the last inspection? 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. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 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 Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All service users are subject to a detailed and holistic assessment process prior to admission. EVIDENCE: All service users have a full assessment of their needs prior to admission, and receive detailed information about the facilities provided within the home. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Stocks of medication held within the home are securely stored and administered appropriately. EVIDENCE: The establishment uses the Boots MDS (Monitored Dose System) for the administration of medication. The stocks of medication are securely and appropriately stored within a locked medication room. All staff responsible for administrating medication receive appropriate training. Stocks of medication held reconciled with records kept. A pharmacist inspection takes place every three months, the last pharmacy report identified no issues Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users are encouraged to exercise control and choice over their lives and are asked for their views on the service provided. EVIDENCE: Service users preferences regarding daily living activities are assessed and flexible routines within the establishment promote independence and autonomy. An activities co-ordinator is employed within the establishment and a wide range of social and recreational opportunities are provided for the service users to participate in if they choose to do so. The activities take place at various times of the day and evening and include: bingo, quizzes, skittles, bowls, word games, golf, discussion group, live entertainment, speakers on various topics of interest, chair exercises, music and ‘regular religious services. The activities on offer are displayed in the entrance hall of the home. Service users receive a varied and nutritious diet, the main meal of the day is served at lunchtime, and the luncheon being served on the day of the inspection consisted of: Admirals pie or braised sausage, served with creamed potatoes, peas and roasted tomatoes, followed by a choice of eves pudding and custard, or ice cream or yoghurt. A choice of either red or white wine, sherry or cranberry or orange juice is served with the meal. The tables are
Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 11 attractively set with vegetables being served in tureens on the table. Tea, coffee, juice and water are freely available at all times. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has robust systems to ensure that service users are safeguarded from abuse and that complaints will be dealt with promptly. EVIDENCE: The establishment adheres to the corporate Anchor complaints procedure. Leaflets detailing the procedure to follow are displayed in the reception area of the home. All staff receive training in the protection of vulnerable adults. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 The home is well maintained, with high standards of cleanliness throughout, providing a pleasant and safe environment for service users. EVIDENCE: The establishment is situated in a residential area in the Hipperholme district of Halifax with local shops and community facilities nearby. The property is purpose built and is well maintained throughout. The service users private accommodation consists of forty one individual bed-sitting rooms all equipped with en-suite facilities and a kitchenette area complete with a fridge. Service users furnish and equip their rooms with their own furnishings which results in each room being highly personalized which in turn aids orientation and independence. All bedroom doors are equipped with a suitable lock, door bell and letter box. In addition to the private accommodation there are spacious and comfortable communal facilities which are shortly to be redecorated. Well maintained and accessible garden areas are available for the use of the service users in the warmer
Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 14 weather. Additional accommodation is in the process of being created, a variation application has yet to be made to the Commission for Social Care Inspection to register the additional rooms. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,38 The home is well run and managed effectively, with robust health and safety procedures in place. EVIDENCE: Since the last inspection the previous registered manager of the home has resigned and the home is being managed by an acting manager. An application has been submitted to the CSCI for registration. Service users are encouraged to manage their own finances, however, any money held on behalf of a resident is held in the Anchor residents personal money bank account, individual statements are available. Health and safety policies and procedures are in place, with all members of staff receiving mandatory training in safe working practices. Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 17 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 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 4 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x 3 x x x x Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sandholme Fold DS0000001005.V280809.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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