Inspection on 01/12/09 for Sandhurst Lodge

This inspection was carried out on 1st December 2009.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandhurst Lodge 29/04/10

Sandhurst Lodge 01/04/10

Sandhurst Lodge 05/11/09

Sandhurst Lodge 23/10/09

Sandhurst Lodge 13/10/09

Sandhurst Lodge 02/10/09

Sandhurst Lodge 22/04/09

Sandhurst Lodge 23/04/08

Sandhurst Lodge 30/04/07

Sandhurst Lodge 20/09/06

Sandhurst Lodge 27/06/06

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report Care homes for older people Name: Address: Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rachel Geary     Date: 0 1 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL 01234352051 F/P01234352051 sandhurst_lodge@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Dr Surinder Kumar Gulati Name of registered manager (if applicable) Type of registration: Number of places registered: care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia physical disability Additional conditions: Date of last inspection Brief description of the care home Sandhurst Lodge is a care home registered to accomodate up to 10 people whose primary care needs on admission fall within one of the following categories: old age, dementia, mental disorder (excluding learning disabilities) and physical disabilities. The home is located on a busy main road in the heart of Bedford town within close proximity to the local hospital, amenities including transport links. The accommodation is set out over three floors - accessible via a staircase and a shaft lift. All bedrooms are single occupancy and communal facilities include a small lounge and Care Homes for Older People Page 4 of 40 Over 65 10 10 10 0 0 0 0 2 1 0 2 0 0 9 Brief description of the care home dining room on the ground floor. There is one assisted bath and one shower, which would not be accessible for people with a physical disability. There are no ensuite facilties and there is limited outside space. At the time of this visit, work was in progress to extend the home to create a further 7 bedrooms. Information about the home is available within the Statement of Purpose (SoP) and Service User Guide (SUG). Both are available within the home along with a copy of the most recent inspection report for this service. The SoP states that the fees for the home at the current time are £457.06 per week upwards. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: A key inspection is a thorough type of inspection when we look at all of the key aspects of a service. For this key inspection, we looked at all the information that we have received or asked for since the last inspection of this service on 22nd April 2009. This included notifications, which is information about the service that the home has to tell us about by law. We also looked at information that we asked the home to send us before and following our visit. And information shared with us by other people. The inspection included an unannounced visit to the home which lasted nearly 7 hours. During the visit to the home we met most of the people who live there. Some people were able to talk about what it is like to live at the home. Some people did not use Care Homes for Older People Page 6 of 40 words to communicate, so we observed the way that the staff were supporting them. We also looked at some of the paperwork that the home has to keep such as care plans, risk assessments, staff training records, menus and health and safety records. Our last key inspection in April, highlighted a number of concerns about Sandhurst Lodge and since then, we are aware that Bedford Borough Council, who have a funding and safeguarding role in respect of the people living in the home, have also had a lot of involvement with the home and have made numerous visits to satisfy themselves that the home is complying with contractual obligations. This involvement was still ongoing at the time of this inspection. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 40 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 40 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some useful information has been produced for prospective service users, but more detail is required to ensure people are clear about the objectives and philosophy of the service provided by the home. Evidence: Following our last Key Inspection of this service we wrote: Information about the home has been produced in the form of a Service User Guide (SUG) and a Statement of Purpose (SoP)... Although both the SoP and SUG contain some useful information for prospective service users and their representatives, evidence from this inspection showed that some of the information within these documents is not completely accurate. For example statements about the home offering a wide range of menus (see daily life and social activities section of this report). And The SUG also does not contain all the required information at the current time. There was nothing specific in the SoP about how the home provides for the needs of the people that it is registered to look after. Sandhurst Lodge is registered to provide personal care and Care Homes for Older People Page 11 of 40 Evidence: accommodation for up to 10 people whose primary care needs on admission fall within one of the following categories: old age, mental disorder, dementia and physical disabilities. If a home says it provides for the needs of people in any of these categories, it should make clear in the SoP exactly how this is done. It should also make clear about the arrangements for accommodating people who dont have dementia with people who do. Many people with dementia can be properly cared for in an older persons care home however, providers need to show they have thought about the possibility of conflicting needs and how these are to be managed. To date, the SUG and SoP have only been produced in a standard format. This was still the case at the time of this inspection although there was evidence that some changes had been made to these documents. After the inspection we received an email from the home which stated that: The service users guide and statement of purpose is still being worked on with the new manager and we hope to get it tweaked to a very high standard, allowing them to demonstrate the facilities and service offered at Sandhurst Lodge. There had been no new admissions since the last key inspection. But there was evidence that peoples needs are assessed prior to moving into the home, and that information gathered through the assessment process is kept under review and updated. However in our last key inspection report for this service we wrote about the lack of suitable bathing/shower facilities for someone living at the home. This was still the case at the time of this inspection (see health and personal care needs section of this report). This had clearly not been assessed as part of the persons personal care needs prior to admission, which is a concern. Sandhurst Lodge does not provide Intermediate Care at the current time. Care Homes for Older People Page 12 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole peoples health and personal care needs are met. But the home must always ensure that all equipment necessary to promote the well-being and health needs of people, is made available prior to them moving in. Evidence: On the 5.11.09 we carried out a random inspection of this service and reported that: There were two sets of care plans in the file we sampled. The care plans detailed how and why most aspects of care were to be provided, but we did not see how the plans had been reviewed. We did see some hand written notes of changes to the original plans (written on 16/04/09), but these changes were not dated. There was a signature confirming that plans had been reviewed in October 2009. On this occasion there was evidence of care plans being in place and reviewed on a regular basis and updated as required. For example one person had been discharged from hospital the previous day and the manager had begun to update their care plan to reflect this. There was also evidence that Bedford Borough Council, who fund all of the people currently living at the home, were carrying out their own need assessment Care Homes for Older People Page 13 of 40 Evidence: reviews. Care plans were clear but would benefit from further detail about each persons routine and individual preferences. The manager confirmed that she was aware of this and planned to develop the existing plans. It was sometimes hard to follow the care provided to someone because of the number of forms that were being used. The manager said she was planning to reduce the number of forms to improve this. Despite this, there was evidence that peoples basic needs were being met including regular health check ups and weight monitoring. Risk assessments were seen which included areas of concern as identified in care plans such as challenging behaviour, falls and nutrition. These still needed to be updated for the person that had just come out of hospital as some of their needs had changed. We were told that another person living in the home was was developing a pressure sore. Appropriate action had been taken by the manager in arranging for this to be assessed by a person trained to do so. It was discussed that the persons health had deteriorated of late, but this was the same person that we wrote about in our April report who had not been able to have a shower or bath since they had been admitted to the home over a year ago. This was due to a lack of bathing/shower facilities suited to their particular needs. Prior to this inspection, we asked the registered provider to tell us how they were going to address the situation, and we were told that a new wet room was being built. At the time of this inspection however, the wet room had still not been completed. We were told it would be ready the following week. There was evidence that despite this, the personal care needs of the person in question were being met in a way that reflected their personal wishes. During our inspection on the 5.11.09, we observed that: The Medication Administration Records (MAR) were neatly kept. We noted that omission codes were used when a medication was not given for any reason and that staff always signed when they gave medications. There were no gaps in the recordings. We looked at the NOMAD packs (the blister packaging that most of the medications are packed in by the pharmacy). People had received all the medications they were due. However where medications were given as required (PRN), because any unused medication carried over from the previous month were not recorded and added to the total, we were unable to reconcile these medications. For example, one resident had received a Care Homes for Older People Page 14 of 40 Evidence: 100 paracetamol on 31/10/09 and this was recorded. It was also clearly recorded that 12 tablets, in divided doses, had been given. However when we counted the tablets held by the home there were 96 rather than the 88 we expected to find. The member of staff who had administered the medication that morning had been trained to do so and had a certificate to support the training. On this occasion there was a clear system in place for medication stock control and for the disposal of surplus medication. One persons medication had recently been changed and the manager was making appropriate arrangements to ensure the correct medication and administration records were in place. However, we did see some confidential prescription information in the dining room stuck on the menu wipe board. Staff told us that they do not have access to the office when the manager and provider are not not there. An extension to the building to increase the number of registered places was underway. We were told that when this was complete, there would be a new dedicated staff area which would eliminate the need for medication and paperwork storage in communal areas intended for the people living in the home. We observed staff treating people with dignity and respect. One person was quite frail having just come out of hospital. A member of staff helped them to drink a hot drink from a normal tea cup instead of providing a beaker. Staff also supported the person to eat some sandwiches for tea rather than providing a soft option, which the person appeared to be happy with. Care Homes for Older People Page 15 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The different needs of the people living in the home, alongside staffing levels and the physical environment, means that people are not enabled to maximise personal autonomy and choice. Meals are not taken in a congenial setting and activities do not adequately suit the needs, preferences and capacities of all the people living there. Evidence: At the beginning of the inspection we sat in the lounge. The television was on but 2 people sitting in the lounge were not watching it or engaged with any other activity. No staff were present although there was a student who had started their placement the previous day. We were told about some outings that had been arranged earlier in the year for some of the people living in the home. It was said how much people had enjoyed these. At the time of this inspection there were only 7 people living in the home and there were 2 care staff on duty for each morning and afternoon shift to provide all personal care, activities and meals/drinks. It was said by staff that the current staffing levels would not allow for people to be taken out of the home for activities. Care Homes for Older People Page 16 of 40 Evidence: Staff were observed doing their best to engage with people when they could but they were kept busy. We did not see people being supported to participate in any meaningful activities. For example, we sat in the dining room for over an hour before and after tea. For approximately 15 minutes before tea, 5 of the 7 people living in the home were also sat in the dining room. Staff came in and out to lay the table and to ask people what they wanted to eat and drink. We observed how 2 people became quite agitated with others who were grinding their teeth, banging on the table or becoming repetitive with their speech. We noted in the case of 1 person that they were sat directly opposite the person that was the cause of their agitation. The person told us they did not feel able to ask to eat somewhere else, such as their bedroom. Staff confirmed they preferred to observe some people eating incase they choked. The current dining room is small and there was no where else for the person to move to in order to remain in this room. The 2 members of staff prepared and served the meal and helped people to eat where needed. They didnt have the time to spend with people engaging them in conversation or other distraction activities. We noted times when people were unsupervised because staff were occupied elsewhere. We were told about 1 person who requires 2 carers to provide personal care for up to 45 minutes in the evening. Whilst this care is being provided, staff are not able to keep a constant eye on the other people in the home. At one point, we turned the music up on the radio in the dining room for 1 person who smiled and then started singing along. We were told that they liked music but had none of their own. We were also told that they would sit and watch TV if they had company but otherwise they would wander about. When we spoke to the manager and registered provider about the lack of specialist activities and facilities for people with dementia care needs we were told that a digital photo frame had been provided, that staff look at photo albums with 1 person and there were plans to provide reminiscence and aromatherapy sessions. There was nothing to show that people are freely able or encouraged to engage in meaningful tasks such as domestic chores. We discussed this with staff who told us that some people sometimes help with folding laundry. They also said that they used to help 1 person who also has a learning disability, to clean their room. This was not happening because the home had employed someone to clean, and staffing levels did not support this type of 1:1 activity. We saw 1 person coming and going independently from the home to a local shop. They did not have a key and had to wait to be let out of the home by staff and let Care Homes for Older People Page 17 of 40 Evidence: back in again. There appeared to be a limited understanding around restraint issues in the home and the practice that we observed was focused on keeping other people in the home safe rather than prioritising the individual human rights of the person wanting to go to the shop. Appropriate use of restrictions to prevent serious harm is not a deprivation of liberty, but this particular situation must be reviewed to ensure that the persons liberty is not being deprived without proper justification. We fed our observation about this to one of the homes owners after the inspection but by the time of writing we had not received any assurance that anything had been done in relation to this. There was evidence that people are supported to maintain contact with their families, friends and representatives where they have this involvement. At our last key inspection we said that: There was a large wipe board in the dining room which had the menu for the day written on it. Copies of previous menus were requested but not provided as the home does not appear to keep paper records. It is a regulatory requirement to keep records of the food provided. This was the still the case at the time of this inspection although 4 weekly menus were now being used. These did not record the actual food provided and eaten however. This was explained to one of the homes owners and shortly after the inspection, we were provided with evidence that written records of the food provided at each meal were now being maintained. We were told that the 4 weekly menus were going to be changed because people living in the home did not like everything that was in them. There was still no choice of meal on the menus that we saw. 1 person told us that the food was alright but it was mainly mince and potatoes. This was the case on the day of the inspection and we looked at the menu for 3 days the week after the inspection. This showed that cottage pie, pork chops with mashed potato and chicken casserole with mashed potato had been provided. We looked for alternatives and found very little choice in the kitchen fridge. The cellar which was locked, contained a stock of frozen and dried goods. A small amount of fresh produce was seen but some had started to decay. There were no obvious treats or luxuries. Lunch on the day of the inspection was bolognaise sauce with either mashed potato or jacket potato with tinned fruit or bananas and custard for pudding. Tea included jam Care Homes for Older People Page 18 of 40 Evidence: sandwiches, soup, hard boiled egg and bananas. We spoke to staff and people living in the home and looked at records. We found that 1 person could not eat bananas and another person did not like them. Despite this, 1 was still peeled for them and placed on their plate. After the inspection we received a copy of a food receipt for Lidls supermarket indicating that some more dried goods and fresh fruit and vegetables had been purchased the following day. We were also told that the home has a contract for fresh fruit and veg deliveries every week with a local green grocer who had not been able to deliver that week. Care Homes for Older People Page 19 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place regarding complaints and protection. Evidence: The homes complaints procedure is set out in the Service User Guide and Statement of Purpose. It has not yet been made available in alternative formats. The manager was not aware of any complaints being received by the home since the last key inspection. We are aware however of a number of concerns being raised by the funding authority for this home, Bedford Borough Council (see staffing and management sections of this report). At the time of this inspection there had been a communication breakdown between the home and Bedford Borough Council. We were concerned that the home makes efforts to establish communication with the Council to ensure that proper links are established in the event of there being a safeguarding issue. After the inspection it was confirmed by Bedford Borough Council that communication links had been re-established. There was evidence that staff had been trained to protect the people living in the Care Homes for Older People Page 20 of 40 Evidence: home from abuse. We are not aware of any allegations or incidents of abuse relating to this service since the last inspection. Care Homes for Older People Page 21 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Plans to extend the existing building were underway however, at the time of this inspection the environment was not meeting the physical and social needs of the different people living in the home. Evidence: At the last key inspection we found a number of concerns with the building - and we considered some of these placed people living in the home at risk. The registered provider was asked to tell us how these were going to be remedied. This did not happen when we asked for it but eventually we received an action plan providing most of this information. At the time of this inspection we found that most of the deficits had been remedied or arrangements to do so were underway. An extension to provide a further 7 bedrooms was also still underway and we were told, almost complete. At our last inspection we noted that there had been no suitable shower facilities for 1 person who wanted a shower. This was still the case at the time of this inspection and we were told that this would be addressed the week after this inspection through the provision of a new wet room. We were shown round the new extension which was not yet usable. Contractors were Care Homes for Older People Page 22 of 40 Evidence: still on site. The registered provider had not yet applied to the Commission to register the additional 7 places so will not be able to accommodate more than 10 people until registration has been granted. We noted some good efforts by the home to minimise the disruption to people living in the home and to maintain a comfortable and homely feel. We referred to the lack of communal space in our last key inspection report for this home and have commented on the effect of the minimal dining space in this report (see daily life and social activities section of this report). The new extension will provide a much larger lounge/diner but we have not seen the building plans as yet, so we are not clear if any additional communal space will be provided once all the changes have been made. We were told that the existing dining room is to become another bedroom and the existing lounge will become an activity room but will also provide a walk way through to the new part of the building. There was nothing to indicate that any special consideration had been given in the planning of the new extension with regard to accommodating people with dementia and the mix of needs that the home is currently registered to provide for. The registered provider will need to demonstrate this when making their application to register the additional places. Due to concerns about the service being provided by the home (some of which have been included in our April report), Bedford Borough Council have placed an embargo on any new admissions to the home until January 2010, when the situation will be reviewed. There are currently only 7 people living in the home. One of the owners told us that they are using the opportunity of having some vacant bedrooms to be able to carry out refurbishment works in the old part of the building, once the works in the new part have been completed. We were told that people currently living in the home will be assessed and given first refusal to move into the new bedrooms - all of which have en suite wet rooms. There are no such facilities in the old part of the building. We were shown one ground floor bedroom in the old part of the building that was being prepared for 1 person who had just come out of hospital. We noted there was no window in this room. The homes Statement of Purpose must provide details of this room to ensure that this and future occupants are aware of this, so they are able to make a positive choice about whether or not to accept this room. Care Homes for Older People Page 23 of 40 Evidence: The home has limited outside space. We were told that a tranquillity garden was being planned following completion of the building works. At the time of this inspection anybody wishing to smoke had to do so outside as there was no designated area inside the home. One persons room felt cool and they were heard on several occasions saying they were cold. We used a thermometer and recorded the temperature as 18 degrees Celsius. We felt the radiator in this room and found it to be warm only - despite being turned up to maximum. This was brought to the attention of one of the owners who arranged for an additional heater to be placed in this room as temporary solution. We were able to establish a notable improvement in the temperature of this room before the inspection ended, but we were concerned that this had not been picked up by the home before our inspection. Since the last key inspection of this service we received 2 letters from the local Fire Authority raising concerns about the homes fire safety measures including the use of a key to keep the front door locked. The key is held by a member of staff on duty, placing people at risk in the event of a fire. This arrangement was still in place when we arrived but the manager did arrange for a key to be placed by the front door and to inform all staff and visitors. We are concerned that the home did not take action to address this matter prior to our inspection. We advised the manager and one of the owners who was present, that the arrangement of placing the key by the door should be checked with the Fire Authority for their approval or another way of securing the door found. The Fire Authority have told us that they intend to revisit the home once the building works are complete. No environmental deficits were seen on this occasion that we considered placed people at risk. There was an odour of urine in 1 bedroom which was carpeted, but there was also evidence that this was to be replaced with alternative flooring. Aside from this we found the home to be warm, comfortable and clean. Care Homes for Older People Page 24 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been notable improvements regarding the homes staffing and recruitment practices but this has not been without significant intervention from Bedford Borough Council and the Commission. Staff appear to genuinely care for the people living in the home but a number of changes of manager have resulted in a lack of direction for the staff team who do not have sufficient in-depth knowledge to help them to meet the complex needs of the people living at the home. Evidence: Since the last key inspection of this home we have carried out 4 random inspections of this service. Bedford Borough Council who have a funding and safeguarding role in respect of the people living in the home, have also had a lot of involvement with the home and have made numerous visits to satisfy themselves that the home is complying with contractual obligations. This involvement was ongoing at the time of this inspection. Some of the main concerns have been around staffing levels and the homes recruitment practices. On 2.10.09 we inspected the home and reported that: The Care Quality Commission had been contacted on the morning of the 2nd October 2009, concerns were raised that staffing levels and recruitment systems were not sufficient at the home...We Care Homes for Older People Page 25 of 40 Evidence: looked at the staff rota and met those staff on duty at the time of the inspection. The rota showed that a manager who had been employed via an agency had left two days prior to this visit. The owners reported that they had already taken steps to recruit to the post and this was to be advertised in the local press. One of the owners was acting up in the position of manager until a new manager is appointed. We looked at the staffing rota for the current week, alongside a random selection of other rotas going back to March 2009. These showed that there were 3 staff on duty throughout the day and two waking night staff and a sleep in duty person throughout the night. At the time of this inspection there were 8 people living in the home. We then examined the staff files of 6 people employed since March 2009 to look at recruitment practises. None of the files contained health checks or declarations and this needs to be actioned and was discussed with the owners. 3 of the 6 staff employed had only one written reference and one staff member had none in place within the staff files, only verbal references had been taken for this person. One member of staff, who did have two written references in place, had no previous employment history on their application form. There was one employer details entered under the most recent employment section of the application form; it was explained this business had closed so you were unable to secure a reference from them. However there were two written references, it was explained this was from a past employer where they had worked for two years in a laundrette. The checking of the accuracy and verification of information supplied within an application is a requirement. The documents also in use for references did not allow for their authenticity to be validated either. The other member of staff who had two references in place detailed within their application form that their previous role was that of a carer. However neither reference on their file detailed that they had been employed as a carer. Again it was not possible to verify the authenticity of the references due to the format that is used. It was also noted that most staff had been employed following a POVA First check, prior to the receipt of a CRB. This practise should only occur in exceptional circumstances. Therefore staff had worked at the home with only a POVA First check and without two written references for a period of time. We left an immediate requirement about recruitment of staff at the home, we said that no one is allowed to work in the home until they have two written references and a POVA first check as a minimum. We contacted the service by telephone after we left, we did this to check that the immediate requirement had been acted upon by the owner. The owner confirmed that it had, cover was being arranged and Representatives from Social Services were also helping. On 13.10.09 we returned and reported that: On 2nd October 2009, we carried out a random inspection of Sandhurst Lodge and left an immediate requirement notice relating to recruitment checks for staff working in the home. This resulted in 5 of the staff not being able to work until specified documents had been secured...we found Care Homes for Older People Page 26 of 40 Evidence: evidence on this occasion that the owners were updating and improving the systems for recruitment and vetting checks. But there was still some work to be done to ensure that all staff files are fully compliant with the legal requirements for care homes. We looked at files for people working in the home on the day of the inspection. Copies of recruitment, vetting and training documents were seen. There was no evidence that anyone from the home had verified the authenticity of some of the copied documents. However we did see that this work had begun in other files. We saw one written reference for a member of staff that had been signed after their start date - meaning that the person had started work without proper documentation being in place. There was evidence that a verbal reference had been taken at the time and we were told that this practise had now stopped. Verification of peoples reasons for leaving previous care positions were not always recorded, and there was no declaration about one persons physical and mental fitness on file. We received an email from the home shortly after our inspection on the 2nd October to confirm that these matters were to be remedied by 16th October 2009. A contract of employment was not seen on file for 1 member of staff. We were told the person was new and on probation. This is required information. On the whole we found evidence that gaps in employment history were being explored and recorded for people working in the home. And files that we looked at contained satisfactory Criminal Record Bureau (CRB) disclosures and proof of identity documentation. We did see a reference for one person which contained information that raised some concerns. There was no written record to show that home had sought further information and assurance on this matter at the time. We were told that it had been dealt with verbally only. Rotas were seen and showed us that there were 3 staff on duty through out the day and there was 1 waking and 1 sleeping staff on duty at night - for the 8 people living in the home. There was no manager in post at the time of our inspection and we were told that one of the owners was temporarily acting as manager, and that action had been taken to recruit a permanent manager. After an inspection on 23.10.09 we wrote: The Care Quality Commission received information on 22nd October 2009, concerns were raised that staffing levels and recruitment systems may still not be sufficient at the home. In addition we were advised that there maybe a high level of noise, caused by building works being carried out in the home...We looked at recruitment practises relating to four staff and measured these against the requirements under the relevant regulations. In addition we looked at the area of the home where building contractors were working and spoke with the staff on duty. One person had been identified through the CRB check by Bedford shire Borough Council as not being suitable to work in the home. Through examination of records, speaking with staff on duty and discussion with the owners it was confirmed that this person no longer worked at the home. Three staff files were Care Homes for Older People Page 27 of 40 Evidence: examined. Two staff files had the documents needed in place, photocopies of identification cards and working status were in place, alongside references and CRB checks. The third file examined did not contain two written references. However this employee was employed at this service 11 years ago. It is acknowledged that the person was not appointed by the present owners, through discussion on the day of this inspection the owners are now going to request two written character references for this person. As advised even if the current owners did not appoint an employee they are now responsible for ensuring all staff files contain all documents in accordance with the regulations. We looked at the staff rota that was on display in the dining area of the home. This rota showed that there were 3 staff members on duty on the early and late shift. We met the three staff on duty, through discussion they confirmed that the rota was accurate and that there are 3 staff on duty. During the inspection there was no noise heard from the building contractors on site. Staff advised that the final structural work had been completed on Monday 19th October 2009. We inspected the home again on 5.11.09 when we reported that: At the start of the inspection there were three care staff on duty supporting the seven residents. One resident had moved to a nursing provision the previous day. One carer was identified as being in charge of the shift. She told us she was not currently employed as a senior carer, but had worked in this capacity in the past in another home. She conducted herself appropriately and aided the inspection process. We were told that there was currently no manager employed. The carer tried to contact Mrs Gulati and Mr Gulati junior, the son of the providers. Neither were immediately available, but we were able to speak to Mr Gulati junior on the telephone. Both arrived at the home before the end of the inspection and received the feed-back. We were told that the most recent manager had not been given a contract at the end of her probation period. We were told that the post had been advertised and interviews had taken place, a final decision was being made that day. We were given the name of the person considered appropriate for the role...We did see good relationships between the staff on duty and the residents. We are aware that there have been several changes of manager since we last inspected the home in April 2009. On this occasion, rotas were seen which indicated that there were 3 staff on duty in the morning in addition to the manager and one of the owners. It became clear however that 1 person recorded as a care member of staff was not providing a direct care service. We spoke to one of the owners about rotas being legal documents and that these should make clear who is working in the home and their role. Shortly after Care Homes for Older People Page 28 of 40 Evidence: this inspection we received confirmation that this situation had been addressed. We established that there are now only 2 care staff on duty in the morning and afternoon to support the 7 people living in the home. At night there is 1 sleeping in and 1 waking person. There was no training plan for the home but there was evidence that staff had attended basic training relevant to the majority of the assessed needs of the people living at the home. The manager told us that she had a qualification equivalent to an NVQ 2 in dementia care. We have reported on staffing levels and our observations from this inspection earlier in this report. The registered provider will need to ensure that they risk assess staffing levels against the assessed needs of the people living in the home and keep this situation under review. Our inspection highlighted that staff were not clear about how to go about providing meaningful stimulation to people with dementia care needs. There was evidence that staff had received basic training in dementia awareness but they will need further support and training if the home wishes to continue to market itself as a specialist dementia care service. Care Homes for Older People Page 29 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Findings from this inspection indicate that a number of improvements have been made, and importantly that the registered provider wants to comply with regulatory requirements and the council in improving the quality of service provided. However a significant improvement journey still lies ahead. Inconsistencies in the homes management have not secured necessary improvements or progress in a number of areas. A failure to respond swiftly to contractual arrangements and regulatory requirements has resulted in a significant amount of intervention from us and the council. Some of the improvements appear to have only been made as a direct result of this involvement. We have therefore lost some confidence in the provider and we need to see evidence that this situation can be turned round swiftly without further intervention and disruption to the people living in the home. If this does not happen then the Commission will consider taking further enforcement action. The owners must ensure that they are fully aware of their responsibilities as Registered Providers and all the regulations that they are legally obliged to comply Care Homes for Older People Page 30 of 40 Judgement: with. Evidence: Our last key inspection in April, highlighted a number of concerns regarding the service provided by the home. Since then we are aware that Bedford Borough Council, who have a funding and safeguarding role in respect of the people living in the home, have also had a lot of involvement with the home and have made numerous visits to satisfy themselves that the home is complying with contractual obligations. This involvement was ongoing at the time of this inspection. As reported earlier, the council have placed an embargo on further admissions to the home. This is due to be reviewed in January 2010. Some of the main concerns have been about staffing arrangements and recruitment practices. We did speak to one of the owners about the embargo situation and requested confirmation that the home continued to be financially viable given the current number of people living at the home. Verbal reassurance was provided but we have also made a requirement in this report to see the homes business and financial plan for this year and next year. The Commission has carried out 4 random inspections of the home since October and issued an Immediate Requirement notice regarding recruitment practices. We also sent a Warning Letter to the registered provider because they had breached regulatory requirements by failing to tell us about management changes at the home. We are aware that a number of management changes have taken place since April and we have not been kept informed about all of these. However, prior to this inspection we received some detailed information from one of the owners to tell us that another new manager had been appointed. And that they had started working at the home on 23.11.09. The email which was dated 26.11.09 also stated that: The proposed timescale for our new manager to apply for registration is 1 month (this is in order to allow a probationary period to be completed). The home did not have its own quality assurance system although people living in the home were being asked to complete satisfaction questionnaires. We asked for copies of provider visit (regulation 26) reports to be sent to us after our inspection in April. This did not happen until September but we have now received a Care Homes for Older People Page 31 of 40 Evidence: report for the last 3 months. The reports have identified areas needing improvement such as menu options and activities, but findings from this inspection indicate that these have yet to be fully implemented. There was evidence from this inspection that some improvements had been made. There were also areas that need more consideration. For example, findings from this and previous inspections, means that we are not confident that the home has the expertise and facilities to manage the variety of needs that it is registered to provide at the current time. In addition to these needs, we are aware that there is also someone living at the home who has a learning disability - as a secondary need. We have spoken with the manager and one of the owners about this and we have made a requirement in this report for the registered provider to supply us with more detailed information in their Statement of Purpose, about how the home intends to meet the range of needs that it is currently registered to provide for. Or to tell us their plans to revise and reduce the range of needs. It is important that this is considered now because the owners are looking to increase the number of registered places to 17 in the near future. Despite this, we did not find any areas of urgent concern on this occasion and we observed staff caring for people to the best of their ability. As reported earlier there are only 7 people living at the home at the current time. The home had identified a problem with 1 persons financial affairs and appropriate action had been taken with the funding authority to resolve this. In the mean time the person was without any personal monies and it was noted that one of the owners was subsidising the person with their own money to help them to maintain some independence and ultimately some dignity. Following our inspection on the 5.11.09 we wrote that: We looked at the financial arrangements for money held by the home on behalf of residents. Each resident for whom money was held had a cash box and a record was kept of any money received into the home, or used for expenses. Receipts as proof of purchase were kept. One of the balances was out by 4p, and while we appreciate that the money had been rounded up, rather than having odd pence in the box, and that the discrepancy was to the advantage of the resident this did not indicate that accurate records were being kept. Where involved family members were also checking financial records. On this occasion we found that monies being held on behalf of people living in the home were in order and that records tallied. Money was available upon request but Care Homes for Older People Page 32 of 40 Evidence: only the manager and one of the owners had access so this needed to be arranged for a time when they were on duty. This is an improvement on the arrangements found during our April inspection. The manager confirmed that no one living at the home was subject to a (Mental Capacity Act) deprivation of liberty authorisation. Staff told us that they had not had supervision since April. Staff meetings had not been happening regularly either. There was evidence that a staff meeting had been planned for 10.12.09 but the lack of regular supervision will need to be addressed. The local Environmental Health Authority (EHO) had inspected the home on 5.11.09. They had made some recommendations which appeared to be in hand. There were plans for the EHO to revisit the home once the building works had been completed as there were plans to move the kitchen which needed to be re-inspected. Fridge and freezer temperatures were being recorded and there was evidence of other recent safety checks taking place such as gas safety, electrical and fire alarm system checks. Care Homes for Older People Page 33 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 34 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The homes SoP must be revised to provide detailed information about the range of needs that the home is intended to meet and how these will be met. A copy should be forwarded to the Commission. To demonstrate that the home has adequate expertise and facilities to manage the variety of needs that it is currently registered to provide for. 19/01/2010 2 3 14 People must not be admitted 31/12/2009 to the home without a full assessment of their physical care needs and written assurance that these needs will be met. To ensure that the home is suitable for the purpose of meeting peoples needs in Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action respect of their health and welfare. 3 8 12 Confirmation that suitable (for all people living in the home)bathing/shower facilities are in place and fully usable must be received in writing by the Commission. To promote tissue viability and make proper provision for the health and welfare of people living in the home. 4 12 16 Please provide written 31/01/2010 information to the Commission to say how the home intends to meet the routines of daily living and social needs of the people living at the home. This should include the needs of people with dementia. And how these needs will be blended into a service that is registered to accomodate a variety of other needs. To ensure that people are given opportunities for stimulation through leisure and daily living activities which suit their needs, preferences and capacities. 05/01/2010 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 5 14 13 Ensure that assessments and care planning records are consistent with the MCA code of practice guidelines. To ensure that the people are not having their liberty deprived without proper justification. 31/01/2010 6 19 23 Please provide written 19/01/2010 information about how the physical design and layout of the premises - including the new extension will meet the mixed needs of the people living at the home. This should include specific information about individual and communal space and how the needs of people with dementia will be catered for. To ensure that available space is sufficient and that it offers a range of options for the people living at the home. 7 27 18 Risk assess the current staffing levels and ensure they are adequate to meet the assessed needs of the people living in the home. To promote the safety and well being of the people living at Sandhurst Lodge. 31/12/2009 Care Homes for Older People Page 37 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 8 30 18 A copy of the homes 31/01/2010 training needs analysis for the next 12 months must be provided to the Commission. This must reflect the assessed needs of the current users of the service. And the mix of needs that the home is currently registered to provide a service to. To ensure that staff fulfil the aims of the home and are able to meet the changing needs of people living in the home. 9 33 24 The home must establish a quality assurance and quality monitoring system. To ensure that the home is run in the best interests of the people living there. 31/01/2010 10 34 25 The homes business and 19/01/2010 financial plan for this, and the next financial year, must be provided to the Commission. To satisfy us that the home is financially viable for the purpose of achieving the aims and objectives as set out in its Statement of Purpose. Care Homes for Older People Page 38 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 11 36 18 The home must provide staff 15/01/2010 with formal supervision on a regular basis. To ensure that staff understand the aims and purpose of the home and that they are supported in being able to promote this. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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