Inspection on 19/09/08 for Sandhurst

This inspection was carried out on 19th September 2008.

CSCI found this care home to be providing an Adequate service.

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

Sandhurst 20/09/07

Sandhurst 03/08/06

Sandhurst 17/10/05

Sandhurst 07/02/05

Sandhurst 29/07/04

Sandhurst 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2009.

CARE HOMES FOR OLDER PEOPLE Sandhurst 49/51 Abbotsham Road Bideford Devon EX39 3AQ Lead Inspector Susan Taylor Unannounced Inspection 11:45 19 & 22 September 2008 th nd 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 Sandhurst DS0000022118.V368848.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. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandhurst Address 49/51 Abbotsham Road Bideford Devon EX39 3AQ 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) 01237 477195 01237 470601 Mr Klaus-Jurgen Gunter Kothe Mrs Victoria Caroline Kothe Kim Rosalie Cox Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Learning registration, with number disability over 65 years of age (23), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (23), Old age, not falling within any other category (23) Sandhurst DS0000022118.V368848.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 providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia aged 65 years and over (Code DE(E)) Mental disorder aged 65 years and over, excluding learning disability or dementia (Code MD(E)) Learning disability aged 65 years and over (Code LD(E)) The maximum number of service users who can be accommodated is 23. 20th September 2007 2. Date of last inspection Brief Description of the Service: Sandhurst is a care home providing accommodation and personal care for up to 23 people, over the age of 65 years. It is registered to admit people who need care as result of Old Age, Dementia, a Learning Disability and/or a Mental Illness. The home is situated on the outskirts of Bideford. The 3-storey home consists of two adjoining houses, built in the Victorian era. The rooms are mainly single but some doubles are available. There is a lounge and a dining room on the ground floor. The 2nd floor (attic area) has room for 2 flatlets comprising of bedroom en suite and lounge. There are stair lifts between all three floors. The fees currently charged by this service are between £288 to £381. Chiropody, toiletries, newspapers/magazines, personal items, clothing and hairdressing are additional variable costs which are not included in the fees. Copies of the inspection report are kept in the office of the home but are available on request. Sandhurst DS0000022118.V368848.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 One star. This means the people who use this service experience Adequate quality outcomes. This was a key inspection of Sandhurst under the Inspecting for better lives arrangements. We were at the home with people for 8.5 hours over two days. The purpose for the inspection was to look at key standards covering: choice of home; individual needs and choices; lifestyle; personal and healthcare support; concerns, complaints and protection; environment; staffing and conduct and management of the home. We looked at records, policies and procedures in the office. A tour of the home took place. We sent surveys to all the staff and received none back. We tracked the care of four people and met some of their relatives. We also looked at the care plans, medical records and daily notes for these 4 people. We spoke to another 10 people that live in the home about their experiences there. We watched staff caring for people. We talked to 3 groups of relatives that were visiting their relations. Several weeks before this inspection took place an Annual Quality Assurance Assessment (AQAA) document, which contains general information about the home and the people living there, was completed by the registered manager of the home and returned to the CSCI. We sent surveys to 15 people living in the home and received 9 back. The comments of these people and our observations are in the report. As at September 2008, the fees ranged between £288 to £381 per week for personal care. Extra charges are made for chiropody, hairdressing, newspapers and magazines and toiletries and these vary. People funded have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk People describe Sandhurst as being a “lovely” place to live. Staff are said to be “excellent” and “caring”. What the service does well: Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 6 People thinking of living at Sandhurst have an assessment done to make sure the home can meet their needs. People tell us that good information is shared with them and their family/representatives so that they are able to make a decision about whether to move in or not. People are encouraged to bring personal and sentimental items in with them to make their private rooms homely. Families and friends tell us that they are encouraged to visit regularly and take a part in the care of their loved ones. People enjoy good food and meals are served to them in a comfortable dining room. The home has good procedures in place to deal with complaints, concerns and comments. People are confident that they could raise any concerns with the staff of the home and these would be dealt with properly. Staff undergo a thorough recruitment procedure and staffing levels are good and meet the needs of residents. Staff receive a lots of training and regular updates in health and safety related topics and also subjects relevant to the health and care needs of people living in the home. Staff and people living in the home tell us they have complete confidence in the acting manager. What has improved since the last inspection? A good system for planning care is in place and reviews have taken place with the people living in the home. Medicines are managed safely and have reduced the risk of unnecessary harm to people. People have been listened to and social and recreational activities have been expanded since we last visited. People have much more say in the running of the home and have been asked for feedback about the quality and facilities the service offers. Communal and private areas of the home have been decorated and refurbished. Similarly, regular maintenance checks have ensured that the health and safety of people living in the home, staff and visitors has improved. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 7 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. Sandhurst DS0000022118.V368848.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 Sandhurst DS0000022118.V368848.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): 1,3,6 Quality in this outcome area is good. People considering a move to Sandhurst are given enough information about the home to make an informed choice. The home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home and relatives verified in a survey that the home provides sufficient information for them to make decisions about whether to live at the home or not. We met ten people who told us that they had a copy of the service users guide in their room. Seven out of nine people that responded in the survey had received a contract. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 10 The acting manager told us that people are assessed by himself or the deputy manager in their current setting if they are not funded by the local authority. The pre admission form seen included information about a person’s current abilities, medication, next of kin and equipment required. We examined four care files. Information about individuals’ had also been obtained from social services where the person’s care package was publicly funded. We spoke to ten people that live at the home who told us that Sandhurst meets their needs. Similarly, all of the people responding in a survey also verified that their care needs were ‘always’ met. Relatives responding on behalf of their relations in a survey wrote comments like ‘The care given to my mother is second to none. Nothing is too much trouble’ and there is ‘excellent communication in all aspects of care’. Responses such as ‘I’m phoned regularly about any changes in care however small. I am also kept up to date when I visit’ demonstrated that the team communicates well and keeps advocates informed about issues affecting their relation when they have dementia, for example, and therefore lack capacity to make decisions for themselves. Sandhurst DS0000022118.V368848.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 Quality in this outcome area is adequate. Improvements in the completion of risk assessments will ensure that each person who lives at the home, always receives the care that they need and that safe systems to deal with any risks are devised. Medication systems have improved and are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Nine people living in the home returned surveys verified they ‘always’ receive the care and support they need. A relative wrote that their relation has ‘a keyworker…’. Additionally, staff are said to ‘contact the doctor as soon as needed’. Assessments had established what risks there were for individuals’ receiving care. However, when we tracked the outcomes for people we found that these Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 12 were incomplete. For example, a person that had a history of falls did not have an up to date assessment that looked in depth at what might be causing this or measures that should be put in place to reduce the risks for that individual. In August 2008, the person had fallen and the Commission was notified of this accident that led to the individual needing hospital treatment. Prompt and appropriate first aid was given to the individual. We looked at 5 staff files and established that staff are experienced and have received training about first aid. Records highlighted that another person was at risk of choking and therefore had specific nutritional needs. We discussed this with the acting manager and suggested that a tool such as the ‘Malnutrition Universal Screening Tool’ (available at http:/www.bapen.org.uk/must_tool.html) be used. This will ensure that staff are prompted to look into all aspects of a person’s needs and so that individuals are confident that their care plan gives a full picture of how these will be met. In another file we read that the person tended to wander, particularly at night, and this posed some risks for that individual. A pressure mat was highlighted as a measure to reduce the risks highlighted so that staff are alerted to the person’s whereabouts during the night. We saw that this was in place when we looked at the person’s room. The individual’s mental capacity had not been assessed. Such measures need careful assessment and agreement from all stakeholders, including the individual’s advocate. We discussed this with the acting manager who is aware of requirements in the Mental Capacity Act 2005 for there to be ongoing assessment of an individuals capacity at an exact moment about a particular decision/issue. They verified that policies and procedures covering this aspect of care were in the process of development. These will also incorporate the local authority procedures that come into effect in April 2009. In terms of privacy and dignity, a relative responding on behalf of their relation wrote that they always arrive unannounced when they visit and find their mother ‘always well dressed and clean.’ All the people living in the home had a written care plan that had been regularly reviewed. This is an individualized plan about what the person is able to do independently and states what assistance is required from staff in order for the person to maintain their needs. We looked at three care files in detail and one file was partly reviewed. Two care plans provided staff with good information about how to meet people needs. These included plans for managing the care of a person with diabetes or challenging behavior or infection control needs. The plans had details about what might alert staff to a person’s condition, deterioration in their health and how to resolve any concerns arising as a result. Two other plans we looked at, however, did not provide enough information for staff to fully understand how to meet peoples Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 13 needs, which contained brief instructions for example, ‘moisturise skin appropriately’ and ‘toilet regularly’. We met a group of nine people in the lounge, they told us that that their healthcare needs are well met. Comments like “I was taken to hospital the other day for a memory test” and the staff are “very professional”. The home uses a monitored dosage system. Senior staff are responsible for stock taking. Records of ordered drugs and a register of controlled drugs were seen and tallied with those being stored. The system was easy to audit and we tracked how medication is managed for four people. Records accurately reflected medication having been given as prescribed by the GP. All medication was kept in a secure place. We observed medication being given to individual’s concerned after lunch and at the evening meal. This was done safely and records were completed appropriately after each person had taken their medication. Other care staff we spoke to said that medicines are only given by staff trained to do this. We examined a random selection of four staff files, two of which were for longer serving employees that had certificates demonstrating this. Particular aspects of the management of medicines had improved since the last inspection. A new refrigerator, specifically for medicines had been purchase and we looked at records, which demonstrated that the temperature was regularly checked. Creams and/or ointments that people had or were being treated with were recorded on the Marrs sheet with the directions of the prescriber and an expiry date recorded. Therefore, the management of medicines has improved and ensures that people are given the correct medication, at the right time. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14 & 15 Quality in this outcome area is good. Routines and activities are flexible for people and they are listened to regarding the choice of daily activity. The diverse needs of people needs to be taken account of, and ensure that everyone leads a full and stimulating life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives responding in a survey told us that there is ‘a very good atmosphere’ at Sandhurst. They tell us that there are activities most days and that fundraising in the past has enabled more entertainment to be arranged. They also feel they are made welcome by being invited to events like a ‘buffet’. We had a discussion with a group of nine people who were satisfied with the programme of activities available to them. Information sent to us by the provider verified that 100 of the service users living at Sandhurst are of Christian faith and that ‘individual religious needs are catered for through the Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 15 local community for residents to visit a place of worship or to attend the homes in house service depending on their religion’. The group told us “the preacher comes this afternoon”. Information sent to us by the manager explained that the programme of activities had been changed as a result of listening to the people living in the home. The group told us “we all like playing bingo and have great prizes”. Additionally, nearly every person in the home had been able to see the local carnival procession as it passed the home. Information sent to us by the manager verified that people that have no family have been supported to use the ‘Time Of Life’ group to take part in different activities within the local community. We spent time in the lounge and dining room observing how staff interacted with people. During the period of observation, activities or stimulation for these people with cognitive impairment was still limited and people were seen unoccupied and confused on occasions. When staff did engaged with people they demonstrated genuine warmth and attention, which people appeared to respond to and enjoy. Activities were group based and did not always reflect the level of ability that the person had given the stage of their dementia for example. To illustrate this point, some people might be more responsive to sensory activities such as painting or aromatherapy. Alternatively other people might be more responsive to cognitively based activities, such as a reminiscence quiz. This should be based on assessment of a person’s needs in terms of occupation, interest and capabilities using evidence-based tool such as The ‘Pool Activity level instrument’. This will ensure that activities are person centred and appropriate for individuals’. In surveys people tell us that they get ‘fresh vegetables, cakes, puddings’ all of which are ‘home cooked’ . Their responses told us that the food and menus at the home is ‘always’ good. Similarly, people we spoke to made comments like (the meals are) really good and “tasty”. One person said they had asked for “a fry up and got the works – eggs, bacon, sausage, fried bread, mushrooms and tomato” and was “so full” they had decided not to have any lunch. We saw lunch and the evening meal served during the inspection, both of which were well balanced and appetising. We saw that people were offered at least two different choices and were offered extra helpings. The catering staff explained that they have written details of individuals’ likes and dislikes and can plan menus around these. We were told that special diets such as low fat/sugar had been made for people with diabetes. Sandhurst DS0000022118.V368848.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 & 18 Quality in this outcome area is good. Sandhurst’s policies ensure that people are protected and able to voice their concerns, safe in the knowledge that these will be acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information sent to us by the manager tells us that complaint procedure has been improved to ensure that complaints are consistently recorded and acted upon. 1 complaint was received and upheld. In surveys, 100 people living in the home tell us that they are satisfied that the home listens to them and deals with any concerns in a timely way. We saw a copy of the ‘Alerters guide’. The home also had a whistle blowing policy, which all of the staff we spoke to understand. Kind and caring interactions were observed throughout the day between staff and people living in the home. Staff engaged positively with people who had dementia and demonstrated genuine warmth when engaging those individuals. A relative told us that the staffs were “kind and caring”. Another visitor commented that their relative was “very content”. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 17 Information sent by the provider told us that 63 of the staff holds an NVQ in care, part of which is about safeguarding people. Further 18 staffs are in the process of doing the award. Staff told us that policies and procedures are discussed with them. We looked at training records and saw that ‘Safeguarding Adults’ training had been provided for staff. Information sent to us by the manager verified that no safeguarding or POVA referrals had been made since the last inspection. We observed that people are treated with respect and encouraged to see Sandhurst as their home. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is good. Improvements in the décor and maintenance of the building mean that people live in safe, comfortable and welcoming surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A relative responding on behalf of their relation wrote ‘I always arrive unannounced and the home is always clean and smells fresh’. All of the people living in the home that responded in our survey verified that the home is ‘always’ clean and fresh. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 19 Information sent to us by the manager demonstrated that the maintenance of the home had improved and therefore made the home a safer place for people to live. We looked at the maintenance file, which was well kept and demonstrated that external contractors had been used throughout the year to check compliance of equipment such as the stair lift, fire, hoists, gas and electrical appliances. Information sent to us by the manager verified that there are plans to continue replacing carpets in bedrooms and to decorate in consultation with the people living in the home. Additionally, there are plans to install a new suite in the first floor bathroom. We toured the building and saw that the entrance hall had been decorated and is more welcoming for the people living there and visitors alike. People told us that new furniture for the living and dining rooms had been purchased and they “like the new look”. We observed that two people in the lounge that were sitting on pressure relieving cushions. The new chairs were high back type and particularly suitable for older people. At the last inspection we reported that the electric hoist in one of the bathrooms was showing exposed wires, which could potentially prove a danger to both staff and people living in the home. This matter had been addressed and we saw that regular risk assessments had been completed for equipment like this throughout the home. Staff told us that the management team regularly check equipment to ensure that it is safe for people to use. All of the occupied rooms were clean and comfortable for the people living there. We had a discussion with a group of nine people and they told us that they were always encouraged to “see this as home” and to “bring in [their own] furniture, ornaments to make it homely”. Externally the garden was tidy. People told us that staff had recently helped them get down to the public path in front of the property so that they could watch the Bideford Carnival parade. We were told that at least three people who are less mobile had been unable to do this because the path is uneven and has steps leading down to the road. They had instead watched the parade from the 1st floor lounge or not been involved. Staff verified that there are handling constraints that prevent at least three people being able to go out that might normally do so in a wheelchair. We discussed this with the acting manager who told us that six extra staff worked voluntarily so that people could be helped out onto the path to watch the parade pass by. We recommended that the refurbishment plan for the home should ensure that access is improved for disabled people so that they are not unfairly disadvantaged and are enabled to be as independent as possible. Infection control measures such as hand washing had been discussed with people living in the home and staff. People we spoke to told us that staff “always wash their hands”. Staff told us that gloves and aprons are always Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 20 available and that they are encouraged to use them when delivering personal care. We observed that all of the staff had alcohol gel to clean their hands with. Information sent to us by the manager verified that twenty two staff have done infection control training. Additionally, the Department of Health ‘Essential Steps’ had been used to audit infection control management and an action plan had been put in place. We observed that staff followed safe procedures with regard to separating bed linen and clothing. Therefore, the risk of cross infection to people living at the home is minimised. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. Recruitment practices at Sandhurst are robust and therefore protect the people living there. The training and development programme ensures that competent and knowledgeable staff cares for people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives told us that the staffs responds “quickly” if their relation has to use the call bell. Other relatives described staff as having “hearts of gold” and being “very caring”. We had a discussion with a group of nine people who said they “never have to wait” if they need to be taken to the toilet or want to go to bed. We examined duty rosters for August and September 2008. Most days there were five staff on duty in the morning, three in the afternoon and four through the evening. Additionally every day there was a cook and a domestic working until 2:30 p.m. We were at the home until the evening on the first day and then in the morning on the second day. Over that period we concluded that there were sufficient staff on duty because people’s needs were promptly met. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 22 There is a diverse staff team at Sandhurst; the gender mix matches that of the people living there. We looked at five staff files of individual’s appointed since the last inspection. Relevant pre-employment checks, including references (CRB and POVA checks) had been taken up. Therefore, the recruitment procedures are robust and ensure that individuals’ are suitable to work with vulnerable adults. Training records showed that staff has training in all key areas of health and safety, as well as some specialist areas such as working with people with Dementia. Staff spoken to said that they were offered regular training updates, including opportunities to complete NVQ (National Vocational Qualifications) in care. Information sent to us by the provider tells us that 81 of staff have or are working towards an NVQ2 or above. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate. Temporary management arrangements are meeting the needs of the people living in the home, and the quality of the service is improving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission was informed that the Registered Manager had stepped down from the postion of manager. The deputy manager was ‘acting up’ into the manager position and told us that the provider had asked them to complete an application for registration. They told us Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 24 that they have completed the NVQ level 3 & 4 in care and the Registered Manager’s Award. He told us that he used the internet extensively, in particular the Commission’s professional website, to keep up to update thus ensuring that the care delivered is best practice. Since the inspection, the Commission has received and is processing the application for registration. The provider gave the Commission a reasonable picture of the current situation in the service, in a document entitled AQAA (Annual Quality Assurance Assessment). However, there were areas when more supporting evidence would have been useful to illustrate what the service has done in the last year, and/or explicitly how it is planning to improve. As highlighted under the health and personal care section, risk assessment is an area for improvement and should establish whether people are at risk of falls, choking and have the mental capacity to make decisions about all aspects of their life at the home. We read the results of a quality assurance survey, which sought the views of people living in the home and their relatives that was displayed on the ‘resident’s notice board’. This demonstrated that the service has enhanced the way it seeks the views of people and acts on their suggestions for improvement. A relative responding in a survey wrote that they ‘always feel that XXX are happy and that they are in kind and caring hands’. Additionally, that ‘significant improvements have been seen over the last five years’. Similarly, in a survey a person living at the home wrote ‘I feel like I am living in a hotel. I am happy and content.’ We looked at records showing how money is managed on behalf of three people that live in the home. All were accurate when crosschecked with the balance kept for safekeeping. Entries had been signed for. We discussed best practice with the acting manager and recommended that entries should have two signatures to denote that transactions have been witnessed. We concluded that people’s money is well managed. We spoke to staff during the inspection, which told us that 1:1 supervision sessions were infrequent. We looked at five staff files; four had no record of a supervision session having taken place in 2008. We spoke to the acting manager who verified this was an area that needed to be improved. Regular supervision of staff will ensure that they continue to competently care for people and are aware of best practice. Comprehensive Health & Safety policies and procedures were seen, including a poster displayed near to the office stating who was responsible for implementing and reviewing these. We toured the building and observed that Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 25 cleaning materials were stored securely. Data sheets were in place and staff spoken to understand the risks and strategies to minimise those risks from chemicals used in the building mainly for cleaning and infection control purposes. We observed hand sanitizer being used by staff to minimise the risk of cross infection. Records of accidents were kept and showed that appropriate action had been taken. The fire log was examined and demonstrated that fire drills, had taken place regularly. Similarly, the fire alarm had also been regularly checked. People living in the home, relatives and staff told us that the alarm was checked every week. An engineer had checked the hoists twice in the last 12 months. First aid equipment was clearly labelled. We saw staff following good manual handling practice when moving people from wheelchairs to chairs in the dining room at lunchtime. As reported under environment, at the last inspection we reported that the electric hoist in one of the bathrooms was showing exposed wires, which could potentially prove a danger to both staff and people living in the home. This matter had been addressed and we saw that regular risk assessments had been completed for equipment like this throughout the home. Staff told us that the management team regularly check equipment to ensure that it is safe for people to use. Therefore, regular maintenance has reduced potential hazards to the health and safety of people living at the home. Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 1 x 3 Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 27 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 OP36 Regulation 18(2)(a) Requirement The provider must ensure that staff receive regular one to one supervision so that their care practice is formally reviewed and their training and development needs are identified and planned. This will ensure that staff that follow best practice cares for people. Timescale for action 31/01/09 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 OP8 Good Practice Recommendations The nutritional needs of people living in the home should be known by being properly assessed with a tool such as the ‘Malnutrition Universal Screening Tool’ (available at www.bapen.org.uk). Peoples’ mental capacity should be assessed so that the team are clear about whether a person is able to make decisions about their care and life at Sandburst. If they DS0000022118.V368848.R01.S.doc Version 5.2 Page 28 2. OP8 Sandhurst are unable to do so, the assessment should clearly highlight who will be involved in the process and the issues that need to be addressed for the individual. In particular, mats linked to the call bell system need to be carefully considered and agreed by all stakeholders. 3. OP12 The diverse needs of people are taken into account when organising individual and group activities so that everyone leads a full and stimulating life. For example, use an assessment tool like the ‘Pool Activity level instrument’ to establish exactly what individuals’ are able to do and indentify suitable activities accordingly. Changes to the external grounds should be done to ensure that these areas are accessible and do not unfairly disadvantaged disabled users. This will ensure that all people using the service are enabled to be as independent as possible. Guidance on this issue is available at: http:/www.equalityhumanrights.com 4. OP22 Sandhurst DS0000022118.V368848.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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