Inspection on 15/11/05 for Sandiway Manor

This inspection was carried out on 15th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sandiway Manor 23/12/09

Sandiway Manor 29/08/07

Sandiway Manor 07/08/06

Sandiway Manor 06/05/05

Sandiway Manor 20/01/05

Sandiway Manor 06/08/04

Sandiway Manor 18/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sandiway Manor Norley Road Sandiway Northwich Cheshire CW8 2JW Lead Inspector Sue Dolley Unannounced Inspection 15th November 2005 09:40 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 Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 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. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandiway Manor Address Norley Road Sandiway Northwich Cheshire CW8 2JW 01606 883008 01606 301764 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) Cheshire Residential Homes Trust Mrs Jacqueline Gregson Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 29 service users, within the category of old age (OP) may be accommodated 6th May 2005 Date of last inspection Brief Description of the Service: Sandiway Manor is a care home owned by the Cheshire Residential Homes Trust, a charitable organisation that runs three care homes for older people. Each home is independently run by a committee. The home is in the village of Sandiway, approximately three miles from Northwich. There are a number of shops, a church and other facilities located in the village. There are adequate car parking facilities available at the home. Sandiway Manor was formerly a private house that has been renovated and extended for use as a care home. Sandiway Manor is a three-storey building; service users are accommodated on the ground floor and first floors only. Access between floors is via a passenger lift or the stairs. There are 28 single bedrooms, for service users and all of these rooms have toilet facilities and washbasins fitted. A further bedroom is available as a guest room. This room does not have toilet facilities. Day space consists of 2 lounges and a dining room. There are sufficient numbers of toilets to meet the required standard. There are aids throughout the home to help service users remain independent, including bath hoists, grab rails and in an emergency call bell system. There are large enclosed mature and pleasant gardens with walkways and sitting areas available to service users. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 15th November 2005 over seven hours to assess if the service was meeting the needs of the people who use them and to check the response to the requirement and recommendations made at the last inspection on 6th May 2005. A tour of the premises included all bedrooms and all shared areas such as the lounges, dining room, bathrooms and toilets, kitchen and laundry. The manager, several staff members and 11 residents were spoken to. What the service does well: What has improved since the last inspection? The registered manager completed The Registered Managers Award n June 2005 and staff members have continued to train to achieve appropriate qualifications in caring and to improve their understanding and knowledge. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 6 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. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 The home provides useful written information to enable prospective residents to make an informed choice about the home. Recently admitted residents have not yet been issued with a statement of terms and conditions to agree the services provided and the rights and responsibilities of the resident and provider. The manager meets prospective residents, their families and others to assess whether identified care needs can be met at the home. Trial visits to the home are encouraged and welcomed to enable prospective residents to assess the quality, facilities and suitability. EVIDENCE: A comprehensive care folder has been provided for residents. This provides information regarding the criteria for moving in, assessment, room facilities, call systems and mealtimes. There is practical information about life within the home and the services and assistance available. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 9 The aims and objectives of the home are explained, there is a sample copy of an accommodation agreement, and a copy of the complaints procedure is provided. Previous inspection reports are readily available within the home and available to prospective and existing residents and their supporters. The care files for three recently admitted residents were checked and did not contain a copy of their contract/terms and conditions. See Recommendation 1. The same three care files showed that an assessment of residents needs takes place prior to moving into the home. Each resident had an initial plan of care for daily living. The care plans are reviewed very regularly and the level of care had been adjusted as needs changed. One care file did not include details of skin care, social interaction, weight upon admission, mental awareness and information relating to inappropriate use of alcohol and medication. See Recommendation 2. The registered manager encourages prospective residents and their relatives to visit the home to enable them to meet with staff and residents and to assess the quality, facilities and suitability of the home. One person who was recently admitted, was able to stay for a short period of convalescence prior to deciding to accept a long- term placement. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,and 11 Staff members have a good knowledge of residents’ individual needs and abilities and are attentive, respectful and courteous. The recording of medication could be improved to ensure medication is administered as often as prescribed. Staff members need to discuss and record residents’ wishes regarding terminal care and arrangements after death to ensure residents’ wishes are met and their death is handled with propriety. EVIDENCE: Each resident has a plan of care to address the main areas of need. Although the three care plans checked were positively written to identify strengths, abilities and difficulties, the information in the daily records did not reflect the actual level of care support and contact provided during each twenty four hour period of care. See Recommendation 3. The sample care files showed that all needs were dated. The intervention required was explained and the expected outcome was recorded. Care needs were reviewed monthly and more often when necessary. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 11 Care plans were agreed with residents and their relatives and risk assessments were in place as appropriate. Thirteen care files did not contain a resident’s photograph, although there had been an intention to obtain and include this information since January 2005. See Requirement 1. The medication administration records for the period from 24.10.05 to 15.11.05 were checked. New medication records and omission codes were in use and staff members were taking time to get used to these changes. Although controlled drugs were well recorded, the main medication administration records check highlighted a need for greater care in recording. There were many unexplained gaps in the recording, which could create problems in accounting for the medication each resident had actually received. Omission code ‘F’ was used but not defined. Some medication was not given as prescribed. Some alterations to the records had been made and were unclear. See Requirement 2. Advice was given to keep the controlled drugs record securely and to ensure all items of medication including homely remedies items are labelled. A clear policy provides guidance to staff in the event of a death occurring, including any special religious considerations. The registered manager continues to try to seek sensitive information from residents and their relatives regarding their wishes on terminal care and arrangements after death. None of the three care files checked contained details of wishes regarding terminal care and arrangements after death. See Recommendation 4. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None National Minimum Standards 12,13,14 and 15 were assessed at the previous inspection on 6th May 2005. EVIDENCE: Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,and 17 Arrangements for responding to residents and relatives concerns and complaints are satisfactory. Residents can be provided with information regarding advocacy services to ensure they can obtain advice and support when necessary. EVIDENCE: The home has a written complaints procedure included in the residents’ information folders. The home’s management aims to deal with any concerns prior to these developing into complaints. Each month a different committee member visits to speak with residents about their thoughts on the standard of care provided. The findings are reported to the chair of the committee and at friends meetings to ensure satisfaction and quality assurance. Residents confirmed that they knew what to do if they had a complaint and residents and visitors said that staff members respond quickly to any matters raised. One complaint record was seen and the complaint had been satisfactorily responded to. The residents are enabled to exercise their legal rights and postal voting can be arranged when necessary. Residents can be advised of advocacy services to assist them. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,21,22,23,24,and 25 Sandiway Manor provides a welcoming environment in which to live. The premises are clean, well furnished and equipped for the comfort of residents. EVIDENCE: The home is well maintained and clean. It is decorated to a good standard and this helps to create a well-presented, comfortable and homely environment for residents. The programme of redecoration planned will address redecoration work necessary following electrical rewiring. The attractive grounds are accessible to residents and the building complies with the requirements of the local fire service and environmental health department. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 15 All bedrooms are en-suite with hand basin facilities. Accessible toilets throughout the premises and bathrooms are well equipped. A separate toilet area to the older part of the building contains two toilets. This does not have satisfactory wash hand facilities. The wash hand facilities are reached via two steps and by aid of a handrail. This area could present a risk to hygiene and would benefit from refurbishment and improvement. See Recommendation 5. A shaft lift, grab rails and other aids have been provided to enable residents to have access to all parts of the home. There was evidence to show that the lift had been regularly serviced. A call bell is available in all rooms. The home is satisfactorily adapted to meet the needs of residents. Individual needs are assessed before residents move in and specialist advice and equipment is obtained as necessary. Some mobility equipment is made available via referrals to physiotherapists and occupational therapists and via a community loan service. All bedrooms are more than 12sq. m. Room dimensions and layout options match individual needs and choice and ensure that there is room to enable access for carers and any equipment needed. Bedrooms are personalised and comfortable. Risk assessments have been completed to reduce risks of burns and scalds. Radiator covers are being provided, and temperature control valves have been fitted to some sink areas Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 NVQ training is continuing. Staff members receive support and encouragement, to achieve their training goals and to ensure they are competent and confident in their caring roles. EVIDENCE: Staff training and qualification is encouraged and supported within the home. Approximately 60 of care staff have achieved NVQ level 2 or above. One member of staff is an NVQ assessor. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,36,37 and 38 The registered manager is experienced in the provision of care to older people and she continues to update her skills and knowledge. The residents and staff benefit from a clear leadership and management approach within the home, which promotes their health, safety, welfare and interests. EVIDENCE: The registered manager is a qualified nurse. She is competent and experienced and updates her skills and knowledge and completed the Registered Managers Award in June 2005. The registered manager is supported by, a deputy and the staff team and management committee. Residents have a high level of contact with the management of the home, which promotes satisfaction from all parties. The processes of managing and running the home, are open and transparent and suggestions for improvement within the home are encouraged, welcomed and acted upon. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 18 The financial status of the home is discussed at the Annual General Meeting and records are kept of all transactions entered into. A surveying company have recently been employed to report on the structural condition of the three linked homes. Upon receipt of the surveyors report all planned redecoration work will commence. Staff members are closely monitored and are in daily discussion with the registered manager regarding all aspects of practice and supervision is part of the normal management process. Since the previous inspection formal and recorded supervision has taken place infrequently due to staff sickness. See Recommendation 6. Residents have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records. Individual records are secure. Due to staff sickness some records regarding care planning are not as up to date as at previous inspections and some new residents had not been provided with a contract/ statement of terms and conditions. The management team endeavours to ensure the health, safety, and welfare of residents and staff are promoted and protected. Mandatory training, for example moving and handling, health and safety, and first aid training, is available for staff members as necessary. Twelve staff accident records were checked and all were thoroughly completed. The accident and incident records relating to residents were checked. Two incident records relating to drug errors were not fully recorded and advice was given regarding this at feedback to the inspection. The fire precautions record book was checked and all main fire safety checks had been undertaken, as appropriate and emergency lighting checks had been completed. Fire evacuation practices were overdue. See Requirement 3. Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X 3 3 3 3 3 3 X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X 2 3 2 Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP7 OP9 Regulation 17 13 Requirement Keep a photograph of each resident to aid identification. Satisfactory arrangements must be made for the accurate recording, administration and safekeeping of medication. Staff competence in the administration of medication must be closely monitored.(This requirement was also made at the inspection on 6th May 2005. The timescale of 06.07.05 has expired and remains unmet). Make adequate arrangements for the evacuation, in the event of a fire, of all persons in the care home and safe placement of residents. Timescale for action 31/01/06 31/01/06 3 OP38 23 31/01/06 Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 21 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 3 Refer to Standard OP2 OP4 OP7 Good Practice Recommendations Ensure all residents are provided with a statement of terms and conditions/contract at the point of moving into the home. Ensure all known and pertinent information is recorded in the care plans. The ongoing records kept regarding service users should be completed at least daily to evidence continuity of care and to accurately reflect the level of care and contact provided. (This recommendation was made at the previous inspection on 6th May 2005). Residents wishes concerning terminal care and arrangements after death should be discussed and recorded and carried out. (This recommendation was made at three previous inspections.) Improvements should be made to the identified toilet /hand washing facility to promote hygiene. (This recommendation was made at the previous inspection on 6th May 2005). Ensure care staff members receive formal supervision at least six times a year. 4 OP11 5 OP21 6 OP36 Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 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 Sandiway Manor DS0000006605.V261959.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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