Inspection on 29/05/08 for Sandhurst Rest Home

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Poor 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 Rest Home 22/10/08

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sandhurst Rest Home 142 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector Mrs Sally Gill Unannounced Inspection 29th May 2008 09:25 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 Rest Home DS0000071542.V365268.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 Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandhurst Rest Home Address 142 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL 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) 01424 844405 01424 845144 Sanctuary Care Homes Ltd Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 24. Date of last inspection N/A Brief Description of the Service: Sandhurst Rest Home is registered to provide accommodation for up to 24 older people and admits people with low through to medium dependencies. Sanctuary Care Homes Ltd purchased the home in February 2008. The owners are involved in running of the business. Currently the home is recruiting a manager. A senior member of care staff is acting manager and has day-to-day responsibility. The premise is an older detached building with ground floor extensions added. There are 22 bedrooms on the ground and first floor. Two of these are doubles. Twenty-one rooms have ensuite facilities, although some quite small. A passenger lift provides access to the first floor. There are two assisted bathrooms one on each floor and one assisted shower. The home has a large lounge, conservatory and dining room. The home is non-smoking. The slopping gravel driveway leads to the front of the house, which is level and mainly laid to lawn with trees, shrubs and a flowerbed. To the side is a level paved area with tables and chairs. The home is suitable for wheelchair access. There is parking on the front drive for several cars. The home is located the main road between Pevensey and Little Common. The home is approximately one-mile form local shops, churches, pubs and other community facilities in Little Common. A bus stop is sited approximately 40 metres away. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 5 The staff compliment consists of the acting manager, senior carers, care assistants and ancillary staff. Care staff work a rota that includes three care staff on duty during the day and a carer on duty at night with another person on call sleeping on the premises. Current fees charged at the time of the visit ranged from £346.00 to £500.00 per week. Additional charges are made for hairdressing, dry cleaning, telephone, toiletries, newspapers and chiropody. Previous inspection reports are not available. However this report is available form the home or can be viewed and downloaded from www.csci.org.uk Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key inspection under the new ownership. It was carried out over a period of time and concluded with an unannounced visit to the home between 9.25am and 5.30pm. Staff assisted throughout the visit. Sixteen people were living at the home on the day of the visit including one short-term care person. There were seven vacancies. Surveys were sent to the home for the acting manager to distribute to people that live there and professionals involved in peoples care. Two were returned; a relative completed one. One commented that the new owners are making a lot of improvements that obviously take time to do. The care of three people was tracked to help gain evidence as to what its like to live at Sandhurst Rest Home. Various records were viewed during the inspection and parts of the home and garden viewed. The home returned the annual quality assurance assessment (AQAA) within the required timescale. Information within the AQAA was not sufficient to give a full picture of the home and at times contradicted information gathered during the visit. The quality rating for this service is 0 star. This means that the people who use this service experience poor quality outcomes. People generally receive good care delivered by a committed care team. Systems to support care delivery are poor which leave people at risk if the informal systems breakdown. The lack of a permanent manager is having an impact on staffing and the home and leaves people at risk. What the service does well: People feel the staff team is caring, efficient and look after them very well. One relative said Sandhurst always provides the care and support needed. People are protected by contracts of terms and conditions, which they have agreed with the home. The owners have been proactive in ensuring individuals have an opportunity for informal feedback about the home. They have taken action to address any negative feedback. The home is clean and tidy. People are able to bring in their own personal possessions including furniture, which has resulted in some very personalised and homely rooms. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 7 People benefit from a qualified staff team. The whole care team are all either qualified or working towards a qualification of National Vocational Qualification (NVQ) level 2 or above. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sandhurst Rest Home DS0000071542.V365268.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 Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People do not have the full information to make an informed decision and cannot be sure their needs will be met by the home before making the decision to move in, as their needs have not been assessed. EVIDENCE: People do not have the full information they need to make an informed choice about whether to move in. The statement of purpose and service user guide has been reviewed under the new owners. The Commission received a copy of both documents after the visit. Shortfalls in the document were discussed with the owners. The owners advised the aims and objectives were displayed in the home and new referrals would be given a copy of the resident’s guide. People that live in the home should receive a copy of the updated residents guide. Requirements are made to address the above. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 10 People have agreed terms and conditions with the home. People spoken to confirmed they had agreed contracts of terms and conditions with the home. The contract has been reviewed under the new owners. People had only signed a single sheet containing details of the fee and paying arrangements. It was suggested as good practice that people sign the whole document and both parties retain a copy. People have moved into the home without having their needs assessed therefore cannot be sure these can met. Two people confirmed that they had not had their needs assessed prior to moving in. One person arrived to look round the home after a telephone call and decided to stay there and then. The assessment could not be found on the day of the visit. The other person was previously known to the home as a visitor and has now been staying at the home for 6 or 7 weeks. No assessment has been carried out. The home must undertake a full assessment of needs prior to people moving into the home this must include short term/respite care. People are given the opportunity to visit and assess the home prior to admission but this has lead to poor practice. The Annual Quality Assurance Assessment (AQAA) advised that the pre-admission process includes inviting prospective admissions to come and spend the day at the home and stay for lunch. Accommodation must not be provided to people unless their needs have been assessed. Intermediate care is not provided but short term/respite care can be if vacancies allow. Sandhurst Rest Home DS0000071542.V365268.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are not set out in an individual plan of care. Generally people’s health care needs are met. The medication systems and practices do not fully protect people. The principles of respect, dignity and privacy are generally put into practice. EVIDENCE: People are not involved in the planning of their care and their needs are not all set out in their care plan. The care plan system is computerised. One person did not have a care plan although they had been resident in the home for 6-7 weeks. Care plans and risk assessments examined were very basic in detail and often in accurate although staff were able to give a verbal account. Examples included it was stated that one person suffered from itches, skin rashes, swollen areas and shortness of breath which was all incorrect. Likes and dislikes were not detailed and at times not recorded. Peoples known routines including personal hygiene and other key information such as religion was not recorded within the care plan. One person had been prescribed meal Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 12 replacement drinks (approximately a week ago) and although this information was recorded in the daily notes it was not followed through into the care plan. Risk assessments were generic and not accurate for individual people. Examples included it was stated one person used the bath hoist to have a bath but that person was unable to have a bath due to leg ulcers and had a strip wash. Risk assessments for self-administration of medication were either not in place or inaccurate. An example it was stated that staff should check the medication weekly to ensure medication was taken, and reorder when necessary but there were no audit in place or needed and the person reordered their own medication. Risks apparent in discussion with people were not risk assessed such as a history of falls or panic attacks. Staff advised that they reviewed the care plans monthly. This is the key workers responsibility but one advised there simply isn’t the time on shift at present. Formal reviews of care involving people and others are not happening. People have access to health care services. Some people liaise with the doctor’s surgery themselves. The district nurse visits regularly although there appears to be no communication between them and the home. One person said the nurse had given advice on diet but the home was not aware of this information. The home must ensure it is kept up to date by visiting professionals. Opportunities for physical exercise are on offer twice a week. Staff advised people are weighed monthly although where there are concerns it is more frequent. People are not protected by a robust medication system. The medication is supplied in a monitored dosage system. The supplying chemist undertakes an audit and had done so not long ago. Some sachets of medication were stored without a prescription label and staff’ were unable to advise who these were prescribed for. Medication must not be stored without prescription labels and these must be returned to the chemist. Staff that administer medication has received training. The lunchtime medication administration was observed and the following concerns highlighted. Staff must not handle tablets during administration. Tablets must not be signed for if staff’ are leaving the tablets to be taken at a later time. This must be risk assessed and a code entry used. The Medication Administration Record (MAR) charts must not be signed before staff have observed the administration. The MAR charts were examined. Where medication arrives in bulk this is logged into the home on the MAR. Where additional medication comes in through the month this is not logged into the home and must be. One person had two prescription creams in their bedroom these were not listed on the MAR chart. Handwritten entries were not dated, signed and witnessed. Some medications had apparently been administered but not signed for. No risk assessment was in place for storage of creams in bedrooms. Some generic risk assessments for self-administration were in place but as previous highlighted these were not accurate. Returns are entered into a duplicate book. Although a carrier bag full of medication for someone who had left the home was being stored and had not been recorded in the book. Returns must be logged into the book whilst waiting to be return to provide a clear audit trail. There were no individual PRN guidelines for staff Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 13 for medication prescribed as required. Correct recording procedures were in place for controlled drugs. A requirement is made to address the above. People confirmed that they are treated with respect and their right to privacy is generally upheld. Everyone spoken to confirmed that the staff team are delightful and always respect people’s dignity. They confirmed that staff are very sensitive when assisting with personal hygiene and ensure privacy. One said I know when its staff because they always knock. People have their own private telephone in their room. People confirmed that they have a key to their own room but advised there is a rule they are only able to lock it when they go out for the day. One said you can get other people wandering in here but I tell them to go. This rule needs to be reviewed as the home need to ensure people have privacy when they wish. People are checked every two hours in the night even when they say this can disturbed them. No one had been asked if they wanted to be checked and a risk assessment completed if they chose not to. Sandhurst Rest Home DS0000071542.V365268.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): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People would benefit from more opportunities and a wider range of social, cultural and recreational activities. People are overall satisfied with their meals. Review of some practices could improve people’s autonomy and choices. EVIDENCE: Social and recreational activities do not meet individual’s expectations. An activities programme in place although the owners acknowledged this is an area where improvements can be made. They hope to expand the range of activities and also introduce some outings. Exercises opportunities are available twice a week in addition, nails (manicures) night, scrabble, crosswords and painting. An outsider entertainer visits the home for a session of motivation and music. People also spend time reading, watching television and listening to music. One person has talking books. One person had a volunteer visit to play scrabble but unfortunately the volunteer is not available for the foreseeable future and another has not been found. On the day of the visit most people were spending time alone in their rooms. People said they feel there is little metal stimulation or others they can socialise with. One said Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 15 I don’t join in the activities because I am a bit low in health. People spoke of visitors and that their telephone is a good link to friends and families. People generally do exercise choice and control over their lives. People have been able to bring in their own possessions, which have made some bedrooms very homely. The home is not involved peoples financial affairs. Some things could be done within the home to improve choice and control. Examples are one person is encouraged to walk to the dining room at lunchtime but because they don’t really want to sit with others they only eat a tiny amount of their first course and then leave and have their desert or staff advised often two in their room. It could be considered that the person be allowed to have their choice and their meal in their room, which may encourage a more nutritious diet, and staff could encourage the exercise at some other time in the day. It would appear that some people would be able to help themselves to jugs of drinks and dishes of vegetables if these were put on the meal tables. People receive a balanced diet. Four weekly menus are in place, which have recently been reviewed. There is a choice of starter, main meal and desert with an alternative available. People felt they are not asked for their input to the planned menu. Although one confirmed they had said they liked macaroni cheese and the next day we had it. Salmon and turkey also have recently been introduced at individuals request. One person is on a liquidised diet or meal replacement drink. Problems with sufficient stocks of some foods have been addressed. The supplier for meat has recently been changed following feedback from people and this has been an improvement. One person said they had porridge, honey and prunes for breakfast served on a tray in their room. Lunch on the day of the visit was home made vegetable, lasagne or toad in the hole and pineapple upside down cake. People were offered alternatives for desert. One person complained they didn’t like parsnips, which were on their plate and was advised to leave them. If vegetables are planned with the menu this could be avoided when asking about choices. The broccoli was yellow and did not look fresh although had only been delivered the previous day. Comments about the food included the roast potatoes sometimes come too crispy and I cannot cut them up so end up picking them up with my fingers to eat them, the spinach can be swimming in water so inedible and other vegetables are not drained properly, disappointed with the food its not what it was, lunch on the whole is very good we start with soup, which is usually nice, lunch is adequate lately we’ve had some very nice roast beef, lamb and pork, the meals are home cooked, its good in parts, would like more meat portions are small, sometimes they come round with extra but not always, on the whole alright, suppers are not as good as they used to be you get weary of baked potatoes and soup, could be better the chicken is very nice, it’s a long time from breakfast to coffee, lately some improvement, the suppers vary and you can be offered things which are not really a meal and they’re excellent well cooked and well planned. Sandhurst Rest Home DS0000071542.V365268.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People feel confident to express their concerns. Action taken to address complaints and concerns could be better recorded. People feel safe living in the home. EVIDENCE: People feel able to voice concerns. However one said when asked if they were confident these would be addressed - some people do their best but it can sometimes take some hammering home to get action. One said they would speak to the manager who is a nice man. One said things were generally attended to quickly. Most said the owners are trying hard. A complaints procedure is displayed in every bedroom. The complaints folder was examined. Discussions highlighted three complaints had been received but only one was recorded in the folder. The AQAA acknowledged complaints recording needs to be improved. One owner advised one letter of complaint was at home and the other complaint form was being worked on. Action had been taken to address all complaints. Two were in relation to food and were upheld and one is in relation care, which is still being investigated. It is suggested a complaints log is kept for ease of tracking complaints. The suggestion of grumbles book for minor day-to-day concerns was discussed. The last resident meeting was in February 2008, which would be a venue for people to voice any concerns and suggestions. The new owners have been spending time with people and families to gain feedback on the home and Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 17 during this have begun picking up on some concerns. One owner advised where negative feedback has been received action has been taken which people confirmed. People confirmed that they feel safe living in the home. The AQAA confirms that policies and procedures are in place for safeguarding adults. The owners advised that some staff had recently undertaken protection of vulnerable adults (POVA) training. It is recommended that all staff should have safeguarding adults training. Staff in discussion was clear where to report abuse within the home but were unclear who to report to outside of the home and this should be clear. The AQAA stated that the one of the owners is to undertaken an East Sussex Social Services train the trainer course in safeguarding adults so they can cascade the training to staff. Sandhurst Rest Home DS0000071542.V365268.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 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Work continues to ensure people have a pleasant, comfortable, clean and homely environment, which currently varies in standard. EVIDENCE: People live in a comfortable, homely, safe and maintained home. Parts of the home were viewed during the visit. Since the last visit some communal areas have been redecorated including the lounge, dining room and corridors. The outside of the home has been repainted. A toilet has been replaced and retiled. The owners advised that redecoration of bedrooms is ongoing. New carpet for the communal areas is planned but on hold due to work required after the periodic electrical examination. The parts of the home, which have been redecorated, provide a pleasant homely environment to a good standard for people to live. However in other Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 19 parts the décor is dated and in some areas in poor condition due to wear and tear such as peeling wallpaper and paint and carpets repaired with tape. One person commented on the poor condition of some windows. One relative said my X’s room needs decorating. The lawn area of the garden is maintained. However weeds were apparent in the flowerbed. People had been able to personalise their bedrooms and had to varying degrees resulting in some very nice rooms. The home appeared clean on the day of the visit and no unpleasant odours were apparent. One person said my room and bathroom are cleaned each day – very well. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are experienced, qualified and trained. Staffing has been compromised lately by the dual role of the manager and additional duties required of the small team. People are not fully protected by a robust recruitment process or a thorough staff induction programme. EVIDENCE: People feel their needs are met but staff feel currently they are over stretched. The acting manager advised that usual staffing is three carers on duty during the day plus a cook and a domestic (Monday to Saturday). The registered manager would be surplus to this. The acting manager advised that due to staffing shortages that only about two of their shifts per week had been surplus to the care staff numbers. The rota confirmed this. On the day of the visit three staff were on duty in the morning, which included the acting manager who was part of the care rota. In addition to care staff the person employed to do domestic tasks had been on leave for a month. Staff advised they had been working high numbers of hours lately due to staff leave. Within their care hours they are expected at present to the laundry, cleaning and some of the administration of the home. One of the owners has also been undertaking some cleaning. Staff felt also that when the acting manager was part of the care rota they were often called to deal with things, which left them short. People confirmed that staff are delightful, lovely, efficient, caring and Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 21 look after them very well. However two commented that there were long periods of time when they didn’t see anyone. Other comments were there aren’t enough carers and although the girls that look after us do their best, I feel sometimes it is inadequate. Also the girls are good but there aren’t enough of them. People receive care from a qualified staff team. The home has done very well in that all staff has obtained or is working towards National Vocational Qualification (NVQ) level 2 or above. However given the shortfalls observed in practice such as medication this is clearly not always put into practice, which is reflected in the score of this, standard which would otherwise been excellent (4). Recruitment practices leave people at risk. The recruitment file of the only person recruited since the new owners have taken over was examined. The application form did not contain the full employment history. One references evidenced that there was other current employment not declared on the application form. The other referenced appeared to be from an ex employee of the declared employer and not therefore the current employer. These areas of concern were not evidenced as being picked up. A Criminal Records Bureau (CRB) check and POVA check was in place. The interview assessment had not been completed. One person undertook the interview and good practice would be two. The owners advised that an audit of staff files had been undertaken on all files and shortfalls in paperwork addressed. A requirement is made to have a robust recruitment process in place. Staff training information was not available on the visit but sent to the Commission as requested. The staff file audit has also looked at staff training and shortfalls. The owners advised that induction is not to Skills for Care specification. See standard 38 for mandatory training. Some POVA training has taken place recently and a fire training session was being held on the evening of the visit. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is not robust leaving people at risk. Quality assurance systems are not sufficient to pick up shortfalls that are apparent within the home. EVIDENCE: People cannot be sure that a person who is able to discharge the manager’s responsibility fully is in day-to-day control of the home. There has been an acting manager since February 2008 who has worked hard to keep the home ticking over. They have recently advised the owners they do not wish to be considered for the post of manager as they feel they lack the experience and knowledge required of the role at this time. This unfortunately was apparent during the inspection. The owners advised they are in the process of recruiting Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 23 a manager. One person said the manager here is excellent in his attention and we appreciate this. There are major shortfalls highlighted during the inspection, which are unacceptable and leave people at risk. There is a clear lack of understanding of regulation and what is required in areas such as pre-admission, care planning and risk assessments, medication and recruitment. Quality assurance systems are lacking to highlight shortfalls as required. The acting manager was not aware of any Regulation 26 visits made by the owners, as no reports were available within the home. A requirement is made. The owners advised that three have been completed and were later sent to the Commission. The AQAA was returned within the required timescale. Information within the AQAA was not sufficient to give a full picture of the home and at times contradicted information gathered during the visit. The owners were advised the AQAA needed to contain more information and Choice of Home discussed as an example of the shortfalls. When completing the AQAA care must be taken to ensure people’s confidentiality is not compromised. Quality assurance at present is generally on an informal basis. The new owners are visiting the home 4-5 times per week and spend time talking to people to gain feedback about the home. The home needs to formalise and evidence their quality assurance systems and introduce residents meetings, staff meetings, supervisions and reviews of care as part of quality assurance. Staff said they had not received any supervision and said they do not feel supported at present. One team meeting has been held since February 2008. A lack of management in the home has resulted in a very caring and committed staff team who are delivering quality care to people feeling unsupported and demoralised. The home does not have any dealing with people’s finances. People’s health, safety and welfare could be better protected with improved records. Training figures were not available at the visit but were sent later to the Commission. Some staff has received training in mandatory subjects such as manual handling, fire safety, first aid and food hygiene. The AQAA stated that some staff has recently undertaken infection control. A fire safety course was to be held on the evening of the visit. Hot water temperatures are tested and recorded. Equipment is tested and serviced regularly. Accidents are appropriately recorded. However the system for tracking accident records needs improvement. A fire risk assessment is in place. Fire alarms are tested regularly. Emergency lighting is serviced regularly. The owners are advised to contact the Fire Safety Officer with regard to timescales for regular testing between servicing, as at present this is not undertaken. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 24 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 2 3 1 1 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X N/A 1 1 2 Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 4& Schedule 1&6 Requirement The registered person must have a statement of purpose, which consists of information specified in the regulations and NMS and reflects accurately the home. A copy of the Statement of purpose shall be supplied to the Commission 2 OP1 5(1)(2) & 6 The registered person must have a service user guide, which consists of the information specified in the regulations and NMS and accurately reflects the home. A copy of the service user guide shall be supplied to the Commission and each service user. 3 OP3 14 (1) The registered person must not provide accommodation to a service user at the care home unless a suitably qualified or trained person has assessed the needs of the service user. A copy of the assessment is held Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 26 Timescale for action 29/07/08 29/07/08 05/06/08 on file. There has been suitable consultation regarding the assessment with the service user. 4 OP7 15(1) The registered person must ensure that a care plan is in place for each service user. Care plans must be further developed with people to ensure all care and health needs are identified and staff are have clear information as to how people want to be supported in order to meet those needs. 5 OP7 13 The registered person must ensure that robust risk assessments are undertaken and recorded which include steps staff must take to minimise the risk for all risks. The registered person must have a safe system for medication management. In particular medications must stored with a clear prescription label, all medication must be logged into the home, all prescription medication must be recorded on the MAR chart, handwritten entries on the MAR charts must be dated, signed and witnessed, written PRN instruction must be in place, medications must be safely administered and recorded, accurate risk assessments must be in place for storage of creams in bedrooms and self administration of medications, there must be an audit trail of medication for return. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 27 29/07/08 29/07/08 6 OP9 13(2) 29/06/08 7 OP29 19(1) Schedule 2 The registered person must ensure a robust recruitment process is in place and followed. In particular A full and accurate employment history must be obtained from prospective staff Gaps in employment history must be checked and a written explanation made A reference must be obtained from the current or most recent employer. 05/06/08 8 OP30 OP38 18(1) The home shall ensure that all staff is suitably trained for the work they are to perform. In particular staff receive an induction to Skills for Care specification Have a plan in place to ensure further staff are trained in adult protection (POVA), fire, infection control and manual handling 29/07/08 9 OP31 8&9 The registered person must appoint an individual to manager the care home that is fit to do so. The home must advise the Commission of the arrangements to manage the home in the interim period 29/07/08 10 OP33 24 The registered person must develop formal systems for reviewing and improving the quality of care. The registered person must ensure a copy of the regulation DS0000071542.V365268.R01.S.doc 29/07/08 11 OP33 26 29/06/08 Page 28 Sandhurst Rest Home Version 5.2 26 visit report is held at the home A copy of the report must sent to the Commission 12 OP37 17 & Schedules 2, 3 & 4 The registered person must ensure that all records required by regulation for the effective and efficient running of the business are maintain and accessible for inspection 29/07/08 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 2 Refer to Standard OP18 OP36 Good Practice Recommendations All staff should receive training in safeguarding adults and know the routes to report any abuse outside of the home. Staff should receive supervision at least six times per year. Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandhurst Rest Home DS0000071542.V365268.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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