Inspection on 30/05/07 for Sandholme Fold

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sandholme Fold 25/01/06

Sandholme Fold 01/08/05

Sandholme Fold 03/09/04

Sandholme Fold 25/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandholme Fold Sandholme Crescent Hipperholme Halifax West Yorkshire HX3 8LP Lead Inspector Karen Westhead Key Unannounced Inspection 30th May 2007 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 Sandholme Fold DS0000001005.V339897.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. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandholme Fold Address Sandholme Crescent Hipperholme Halifax West Yorkshire HX3 8LP 01422 202081 01422 206207 sarah.horner@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust 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) Mrs Sarah Jane Horner Care Home 44 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Old age, not falling within any other category (40) Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP; Mental disorder - Code MD and Dementia Code DE(E) The maximum number of service users who can be accommodated is: 44 25th January 2006 2. Date of last inspection Brief Description of the Service: Sandholme Fold is owned and run by Anchor Trust. It is a care home, which does not provide nursing care. It is purpose built and has room to care for up to forty-four older people. Smoking is not allowed on the premises, but residents can smoke in their own bedrooms. It is in a residential area in the Hipperholme district of Halifax. There is a good bus route nearby which runs into the town centre. The home has forty-four single rooms. Forty of these are individual bed-sitting rooms, which have an en-suite toilet and washbasin, and a small kitchenette area. Three rooms have an additional en-suite shower and one room is in a self-contained area, which also has a private lounge, kitchenette with room for a small dining table, and a bathroom. All rooms are unfurnished and residents can bring their own furniture and equipment if they want to. This can help them feel at home and go some way to keeping their independence. There are also communal areas, which are spacious and comfortable and provide a venue for a wide range of social activities to take place and for residents to meet up in groups. There is a passenger lift to the first floor. Sandholme Fold is well maintained throughout and there is a routine programme of refurbishment. There are safe and accessible garden areas with seating and there is ample car parking for staff and visitors. There is good disabled access into the home. The fee charged is between £347.50 to £510.00 per week. This information was provided during the inspection. Residents are charged extra for hairdressing, newspapers, private chiropody treatments and some toiletries. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the Manager. The inspector arrived at 9.00am and left at 2.15pm. At the end of the visit the manager was told how well the home was being run and what was needed to make sure the home meets the standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. The home was last inspected on 25th January 2006. Before the inspection information received about the home was reviewed. This included looking at the number of reported incidents and accidents, the action plan provided following the last inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of records were looked at which covered all aspects of the home and the care provided. All communal areas of the home were seen and some of the residents bedrooms. Most of the day was spent talking to residents, visitors, staff and the manager, to find out what it is like to live and work at Sandholme Fold. Commission for Social Care Inspection (CSCI) questionnaires and post-paid envelopes were left for residents and visitors to complete. During the course of the visit, three relatives and four residents agreed to fill one out and returned these to the inspector. Other visitors and residents were asked for their views and what they said to the inspector is also included in this report. What the service does well: The home is well managed by a competent manager who is supported by a skilled group of staff. Residents and visitors speak highly of the home; ‘it is the best by far in this area’, one relative said. Paperwork is comprehensive and therefore staff know what they need to do to meet residents needs. Anchor Trust is continually looking at their recording systems and find ways to enhance these. For example the plans of care for residents are being reviewed to make the record more user friendly and detailed enough to give an accurate picture. The residents, their families and friends are actively encouraged to share their views about the home and how it should be run. This is one way staff can be sure the home is being run in a way which benefits those living there. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 6 Health and personal needs of each resident are fully met. Staff are given support and guidance by other health care professionals, including district nurses, the mental health team and social services. Staff know their own limitations and when to ask for additional support and advise. For example, the home does not provide nursing care, but this does not mean residents, who develop an illness or condition, cannot still live in the home. If there is agreement with the resident’s doctor and the home can continue to provide care with nursing support from other agencies then this is done. Health and safety is seen as important and risk assessments have been completed to make sure the home is fit for purpose and safe. The layout of the home means all residents have their own private room and this they can furnish themselves. Those residents, who were able to share their view, said they were glad they could bring with them their own things. This is limited due to the amount of space available but such things as their own bed, armchair, sideboard or occasional table had for some become a cherished item of furniture. Those rooms seen were highly personalised and residents said they had been helped by the handyperson to put up pictures and shelves to display their ornaments and photographs. Residents are given ample opportunities to be involved in activities and recreation. The home employs an activity organiser and residents and relatives said this was a key element in the home. There is a structured programme including ‘discussion groups’ which look at every day events in the news and local papers. Residents and their relatives are offered the chance to be involved in the completion of plans of care and are invited to reviews when the care package is looked at to make sure the home is continuing to provide what is needed. What has improved since the last inspection? What they could do better: The home is well run. However, the practice of wedging fire doors open is a problem, which needs to be overcome as this compromises fire safety in the home. Sandholme Fold is a no smoking home, however residents can smoke in their own bedrooms. This is a problem for some residents, who do not Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 7 smoke but say the corridor can smell of tobacco if residents in this area smoke. It is recommended that the manager look at ventilation in these areas. 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. Sandholme Fold DS0000001005.V339897.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 Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 (Standard 6 - N/A, the home does not provide intermediate care) People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents have enough information about the home to decide if it will meet their needs. EVIDENCE: Nine residents told the inspector that they had been helped by their relatives to move into Sandholme Fold because they couldn’t look after themselves at home. They said they had visited the home before deciding to move in and felt the information available to them had been helpful. The home does not accept emergency admissions and has a waiting list in place. When a vacancy arises the room is allocated and taken quickly. All of the residents and relatives who filled out a questionnaire said that they had received enough information about the home and that a contract was provided on admission. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 10 Four plans of care were looked at in detail. These included the most recently admitted person, a resident with poor mobility, a resident who is under Guardianship and a resident who has high dependency needs. The inspector was told that the format of the files was to be changed now all staff had received training. However, the existing files were looked at. All of them included a pre admission assessment. Assessments are carried out by the hospitality manager, who is trained to carry out the visit. Residents are visited in their own home. This means the hospitality manager can get a good idea about the type of care needed. The prospective resident can also ask questions about the home and what moving in will mean to them. A judgement is then made about whether the home can provide the care needed. The admissions process gives prospective residents the opportunity to spend time in the home before moving in. On admission, where possible, an individual member of staff is allocated to give the resident information, special attention, help them to feel welcome and comfortable in their surroundings and ask any further questions. The plans of care were looked at and cross-referenced with other records, including accident forms, medication sheets, risk assessments and daily diary sheets (which record what the resident has done during the day and night.) All residents receive a contract of terms and conditions on admission. The contract is based on the Office of Fair Trading guidance and is clear and easy to understand. The Statement of Purpose and Service User Guide provides enough information for residents and their relatives about the home and what they can expect. Staff said they had read through the information with those residents who have sensory impairment or needed help with documentation. Residents with poor eyesight also told the inspector this had happened. All bedrooms are single. This means residents can have privacy whilst being attended to, by staff, in their own bedrooms and can have time alone if they choose, without being disturbed. Some residents spoke to the inspector in their bedrooms and shared their experiences about moving in to Sandholme Fold and what they thought about the care provided. They all said they were well looked after. The staff team are qualified and experienced to work with the resident group. Staff understand the cultural and diverse expectations of the residents and work within these. Residents have access to the advocacy service. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Health, personal and social care needs are fully met. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Residents at Sandholme Fold receive very good personal and healthcare support, which is ‘person centred’. The Statement of Purpose and Service User Guide explain the type of care the home offers. The staff team are skilled and knowledgeable about the needs of the residents and deliver care in a professional, caring and competent way. Plans of care show the personal and healthcare needs of each resident and how staff will meet these. Staff work in partnership with other professionals to make sure residents are receiving the best possible care. For example, the district nurses in the area visit to attend to residents who require dressings changing or a prescription injection. They are also on call to attend to residents out of hours. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 12 The management of pressure sores is good, where necessary residents have been provided with specialist mattresses and cushions to be used to prevent pressure sores developing. There are aids and equipment in two of the four bathrooms to encourage residents to retain their independence. The manager reviews this regularly to make sure the home can accommodate any changing needs. Staff have received training in the use of this equipment. Two of the four bathrooms are not used, as there is only a step in bath, which residents find hard to use. The manager said she had secured the funding to have a fixed hoist fitted to one of the bathrooms this year and the second bathroom was to be included in the next financial year. Despite this, residents spoken to said they were able to have a bath when they wanted one. Residents who have moved in from the area keep their own doctor. Others are automatically registered with a local surgery. There is a team of district nurses who know the residents and the residents trust. Regular reviews and health appointments are seen as important and systems are in place to make sure these happen, including optical, dental and chiropody treatments. Staff are alert to any changes in mood, behaviour and general wellbeing of each resident. Plans around health are in place and records are carefully updated to give an accurate account of what is required and what has been done. Examples of good practice were seen with regard to residents who are prone to falling, developing pressure sores or may need specialist equipment. Risk assessments are carried out to identify what the risk is and how this is minimised. Falls are monitored and preventative measures are taken to make sure residents are protected, specialist equipment is in place and staff receive adequate training to use it. Moving and handling procedures are designed to safeguard residents and staff and the home has a ‘back care coordinator’ who has the responsibility of making sure staff training is kept up to date. There is a good medication policy in place. Staff understand the procedures and work to it. Some of the residents take care of their own medication and have signed an agreement with the home. Others are happy for the home to oversee this on their behalf. An example of good practice was seen when medication was to be given out at lunchtime. Residents were given the chance to finish their meal without being disturbed when being given medication. Sandholme Fold does not provide nursing care, however admissions are seen as long term whilst ever the staff team can provide the care required. The wishes of each resident about terminal care and the arrangements they want after death is sensitively discussed with residents or their relatives. Their wishes are then recorded. All relatives and residents who filled out a questionnaire said the health care was very good. Relatives said they were kept well informed. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 13 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 excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents at Sandholme Fold make choices about their lifestyle. Social, cultural and recreational activities meet the resident’s expectations. EVIDENCE: Staff focus on each residents right to live the life they choose. Staff do not impose their views on residents but support them in ways, which might improve their quality of life. Staff make sure residents rights are protected. For example residents are treated with respect and dignity and have access to a range of community resources. Residents said they are able to do what they wish, when they wish. There have been two residents meetings since January 2007. These meetings are formal and are used to seek the views of residents about the running of the home. Minutes of the meetings are available for reference. One resident has been nominated as the ‘Residents Representative’ and seeks the views of others about the home and shares this in the meeting. The list of agenda items and discussions shows this is usually a lively exchange and that residents views are put across fairly and are responded to by the staff team. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 14 Routines are very flexible and residents make choices about their lives. For example residents have control over when they get up and go to bed, who they spend time with and whether they join in the structured activities. A main meal is provided at lunchtime and there are always two choices. Meals are served in the main dining room and a smaller dining room on the first floor. The smaller dining area is used by residents who require more assistance and encouragement to sit down to a meal. However if residents wish, they can sit else where in the home to dine. If residents have any difficulties with their meals staff discuss this and come up with solutions. For example, residents who may be unwell or sleep a lot are given assistance to eat and staff will stay with a resident to make sure they are able to finish a meal and receive the nutrition required. Help is offered and given in a discrete way. Residents who due to their method of eating or the effects of a disability are helped to retain their dignity and sense of self-esteem in a way, which is not demeaning. All residents said they enjoyed the meals provided. There is a varied menu available and residents have a choice at each mealtime. Snacks and drinks are provided throughout the day and night. Staff try to encourage residents to eat a healthy diet and monitor weight loss and gain. Staff complete a ‘nutritional screening’ form for residents to assess if they are at risk of being undernourished and if so steps are taken to make sure they receive high calorific foods and snacks and if necessary food and drink intake is recorded. The benefits of reviewing these records were discussed with the manager and staff. A drinks trolley was being taken round and residents were being given a choice of hot or cold drinks, sliced fresh fruit and biscuits. The inspector watched the main meal being served and talked to residents after the meal. The presentation and delivery of the food was very good. Visiting is unrestricted and relatives were seen coming and going throughout the inspection. They are asked to sign in and out for fire safety reasons and said they understood why this was important. All the visitors said they always made to feel welcome. One relative had been at the last residents meeting and had said how welcome she always felt. Another visitor who arrived during a ‘discussion group’ in the main lounge joined in with the group and later said he was delighted with the care and attention his mother got. He said she told him recently that this was a lovely place to be. Activities and recreation are a main feature in the home. All organised activities are recorded and monitored to make sure residents have access to things they enjoy, that activities are age appropriate and that they cover a wide variety of themes to give everyone an opportunity to take part. Activities and trips are also discussed during residents meetings. For residents who prefer not to join in staff record any activity they have been involved in. This is recorded as ‘Quality Time’ and again this is monitored to make sure no one is left out or may become isolated. Staff are sensitive to residents wishes and this is also considered when reviewing the social aspects of individual care. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 15 One resident said she was ‘lucky to still have her wits about her’ and that she was able to find interest in other things in the home and she could tell staff what she needed and when. Residents and visitors spoken with said they thought the activities were very good and that staff played an active role in promoting things in the home. Some activities involved people coming into the home and residents going out which added to community involvement. One resident said the activities were ‘great fun’ and that she had a choice about taking part or not. One visitor said the activities were good Monday to Friday and that their relative was ‘kept busy’ at these times. However ‘Saturdays and particularly Sundays are very quiet, with no activities’. This was discussed with the manager who agreed, weekends are quieter. Residents had asked for a ‘couple of days off’ during a residents meeting. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 16 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, 17 and 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents are able to raise complaints and have access to a complaints procedure. Their rights are protected and they feel safe. EVIDENCE: There had been one complaint to the manager since the last inspection. This had been mainly about food provision and hot meals being served cold. The manager had investigated it and found staff had not been carrying out the correct procedures. An improvement plan had been put in place and this was being closely monitored. The resident had felt this had improved things and she had also been given advice about who to contact if the complaint had not been addressed properly. Residents said they knew who to complain to if they were unhappy. The complaints procedure is available for residents and relatives. All the residents spoken with said they had not had reason to make a complaint so far. Copies of the adult protection procedures and the local authority adult protection procedures are kept in the office, and are available for staff to read. Staff showed a good awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. Training had also been given. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The design and layout of Sandholme Fold allows residents to live in a safe, well maintained and comfortable home. EVIDENCE: There is ample parking in the grounds for staff and visitors. Sandholme Fold is a no smoking home, however residents can smoke in their own bedrooms. This is a problem for some residents, who do not smoke but say the corridor can smell of tobacco if residents in this area smoke. It is recommended that the manager look at ventilation in these areas. The home is well maintained and the standard of decoration and furnishings is excellent. Bedrooms are highly personalised and reflect the tastes of the resident using it. Many of the residents had brought cherished items of furniture, photographs and ornaments with them to make their room feel like Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 18 their own. One resident said ‘It is important for me to have my own bed and furniture. This room is the next best thing to living at home.’ The layout of the building means groups of residents can meet together in one of three communal areas. Residents can meet with friends and relatives in their bedrooms. Some visitors said they always met with their relative in their bedroom and staff always knocked before entering, which they appreciated. Bathrooms and toilets are located around the home. These were found to be clean and tidy. Two of the four baths are assisted. There are locks on the doors and residents can use the facilities in private. The two bathrooms without hoists are included in the next refurbishment programme and one bathroom is to be adapted next year and the remaining bathroom the following year. Residents said there is enough hot water. Water temperatures are monitored and records kept. The home is well lit, clean and tidy. There were no unpleasant odours. This shows that staff are alert to the needs of residents and attend to personal care in an effective way. Relatives and residents said they appreciated the fact that the home was clean and tidy and well decorated. Outside, the home is surrounded by mature gardens with some seating areas for residents and visitors. Some of the residents enjoy bird watching, bird tables, baths and feeders have been put up to encourage bird life and some residents said they really enjoyed this. Relatives tend to the garden and make up hanging baskets and plant seasonal plants. The grass cutting is taken care of by a local contractor. The patio area, at the back of the home, is used by residents where there are raised flowerbeds and benches. The manager is wanting to fit a canopy to the patio area to provide shade, as it can be very hot during the summer. All safety certificates and servicing were in date and valid. Staff have received the necessary training to make sure they know what to do in case of fire and many have been training in health and safety procedures. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff are trained, skilled and enough staff are on duty to support the residents who live at Sandholme Fold. EVIDENCE: All the residents, who talked with the inspector, spoke in positive terms about the manager and staff team. Two residents said staff made them feel safe and that they had confidence in the care being provided. There are enough staff on duty throughout the day and night. Some residents talked about the upset of staff leaving and not being replaced. This had meant ‘agency’ staff were being used. They knew the manager was trying to get ‘good’ staff and knew this took time. Words used by residents and visitors, when talking about staff were ‘approachable, willing to help, nondiscrimatory, they work hard, are always busy and caring’. • One visitor said their relative had lived at the home for six months. But they knew it was a good home because another relative had lived at Sandholme Fold for a number of years and that she was highly satisfied with the care and attention provided then. She knew the manager had changed but felt the home was still very good. DS0000001005.V339897.R01.S.doc Version 5.2 Page 20 Sandholme Fold • • One visitor said they thought staff interacted well with the residents, that they took time to get to know them and were very patient when residents weren’t able to co operate with them. One visitor commented that the staff seemed to reduce on a Sunday meaning there were only ‘skeleton staff’ on duty and that most residents stayed in their rooms apart from meal times. This was discussed with the manager to make sure this did not apply to those staff delivering direct care. Administrative staff and the hospitality manager do not work at weekends unless there is a function or special occasion. Staff have been trained meaning they have the skills and knowledge to deal with the needs of the resident group. All staff have an accurate job description, which sets out their roles and responsibilities. Residents knew the names of staff and seemed to value the relationships they had with them. The staffing structure and duty roster are based around the needs of the residents and not led by staff requirements. There is a good recruitment procedure that makes sure only staff who are suitable to work with vulnerable people are appointed. The manager confirmed that all staff employed in the home had been through a criminal records bureau check. All new staff work alongside a senior member of staff. All staff are recruited subject to a probationary period. This is extended if necessary until the manager is confident they are the right person for the job. Two staff files were looked at in detail. All the necessary checks had been carried out. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The management of the home is based on openness, respect and commitment. The manager is competent and has the necessary skills and qualifications to run the home properly. EVIDENCE: The manager is qualified and has a significant amount of experience of working with older people. The manager is supported by a team of dedicated staff. The manager has a clear vision of what the home provides and what they want to do to further develop the service. Policies and procedures are written in a way, which follows ‘best practice’. Equality and diversity issues are considered when staff are working with residents. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 22 The home carries out an annual quality assurance survey and has systems in place to review its performance as a whole. Staff work practices and performance is discussed during their supervision sessions with senior staff. The views of residents and staff are listened to, valued and acted upon. There are safeguards in place for the correct management of resident’s money. Record keeping relating to resident care and maintenance of the home are very good; therefore staff know what they are doing. These are kept securely and staff know what they have to do to comply with the requirements of the Data Protection Act. The plans of care are written with involvement of residents and their relatives as appropriate. The manager and staff team have a good understanding of the risk assessment process and this is taken into account in the running of the home. A common sense approach is used to minimise risk without restricting the movements of residents. Health and safety systems are regularly reviewed and are kept up to date. Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 4 4 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 4 3 3 4 4 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 4 3 Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(4) Requirement The registered person must make sure fire doors are not kept wedged open. If doors need to be kept open a magnetic device or similar needs to be fitted, which would close the door automatically, should a fire start. The manager should seek the advice of the fire safety officer in the area. The current practice compromises fire safety in the home and must stop with immediate effect. Timescale for action 24/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations It is recommended that the registered person look at the ventilation on corridors where residents bedrooms are who smoke. DS0000001005.V339897.R01.S.doc Version 5.2 Page 25 Sandholme Fold Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandholme Fold DS0000001005.V339897.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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