Inspection on 17/08/07 for Sandley Court Care Home

This inspection was carried out on 17th August 2007.

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

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

Other inspections for this house

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 Sandley Court Care Home 39 Queens Road Southport Merseyside PR9 9ET Lead Inspector Mrs Trish Thomas Key Unannounced Inspection 17th August 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sandley Court Care Home DS0000069299.V346230.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. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandley Court Care Home Address 39 Queens Road Southport Merseyside PR9 9ET 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) 01704545281 02086320972 Accommodating Care (Southport) Limited Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (1) of places Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home only - Code PC, to service users of the following gender:Either Whose primary care needs on admission to the home are within the following categories:Old age not falling within any other category - Code OP, (maximum number of places: 23 Physical disability 1 named service user - code PD, (maximum number of places : 1 The maximum number of service users who can be accommodated is : 23 Date of last inspection 11/10/2006 Brief Description of the Service: Sandley Court is a care home for twenty-three elderly residents, which is owned by Accommodating Care (Southport) Limited and managed by Mrs. Marie Heslin. Sandley Court is a converted dwelling house with an enclosed rear garden and with parking spaces and planting at the front of the building. Bedrooms, bathrooms and lounges are situated on the ground and upper floors. There is a ramp at the front of the home, and a passenger lift for those who are accommodated on upper floors. Sandley Court is situated in a pleasant residential area, which is a short car ride away from Southport town centre where there are public transport links, shops and restaurants. The weekly charges in Sandley Court are £365.00 - £410.00. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was un announced and the methods used to assess the standards in Sandley Court were by asking residents about their experiences of their home and through discussion with the manager, Mrs. Maria Heslin and staff on duty. A tour of the premises and grounds was carried out. Records compiled in Sandley Court, in relation to care, health & safety and staffing were read. To obtain written feedback from relatives and their representatives, a sample of quality questionnaires was read. Reference was also made to the annual quality assurance assessment, which had been completed by the manager and returned to CSCI before the visit. What the service does well: Residents were satisfied with the care they receive in Sandley Court. A lady said, “The staff are helpful and I have no complaints about the care here.” Visiting relatives spoke on behalf of residents saying, “I am very pleased with the service in Sandley Court.” “There are no problems, things are going well, no concerns at all.” The majority of staff have worked in Sandley Court for several years and this provides continuity of care for residents. Staff said they are well supported by management and have the training they need to provide care to the residents. Staff support residents’ diversity and dignity in care giving, and in the lifestyle promoted in Sandley Court. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some inconsistencies were noted in medication records and to protect residents’ wellbeing, and ensure that there is an accurate drugs audit trail the following recommendation is made. The controlled drugs records and stocks are to be checked daily by the senior person on duty and signed for as being in order. Residents’ comments in quality questionnaires would suggest some improvements will be needed in relation to the frequency and types of activities on offer. To ensure that all residents have ongoing social support from staff, a recommendation is made their preferred activities and participation in them is recorded on their care plans. It was evident from residents’ comments and their feedback in questionnaires, that improvements to meals will be needed. To ensure that residents’ food is to their satisfaction, it is Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 7 recommended that consultation with residents is ongoing regarding the quality and content of their meals. Some of the residents said that television picture on some of the channels in their bedrooms is not clear, and a recommendation is given that remedial work is carried out to ensure that they receive good television reception. To ensure that residents’ bedrooms are in good condition, remedial work is recommended to one window (as discussed), which a resident said was letting in a draft and was difficult to open. There are systems in the home to manage environmental risks however, some residents are mentally frail and may not be aware of hazards to their safety. To ensure residents’ safety whilst in the garden, a recommendation is given that risk assessments are carried out in relation to the pond, and the cellar steps and that any identified remedial action is taken. 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. Sandley Court Care Home DS0000069299.V346230.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 Sandley Court Care Home DS0000069299.V346230.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): Quality in this outcome area is good. Residents have had their needs assessed and have the information they need before making the decision to move in to Sandley Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 3. (Standard 6 does not apply as intermediate care is not provided in Sandley Court). Copies of pre-admission assessments were seen in residents’ care files. Social workers and staff from the home had carried out individual assessments of health and social care needs, to ensure that the service in Sandley Court could meet these needs. The outcomes of assessments form the basis of each individual’s care plan. The manager said that residents and their family are fully involved in the process and are encouraged to visit Sandley Court before a decision on moving in is made. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. All residents have a care plans to address their health and personal care needs however improvements will be needed in the management of medication records. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7,8,9,10. All residents have a care plan and the care of four residents was tracked by reading their assessments and care plans and by speaking with them. The care plans, which were seen, addressed a range of health and social care needs for each individual and there was evidence of risk management (including the risk of pressure sores), and review of each person’s needs. The relative of a resident said, “ (Name) is very well cared for and comfortable.” All residents are registered with local doctors and there was evidence in the care files that they have access to paramedical and health services, such as chiropodists, district nurses and specialist treatment in local clinics. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 11 There is a system for managing residents’ prescribed medication and staff who give out medication have received relevant training. The medication management for four residents was checked. There were supplies of each drug in stock and these were secured in a locked cabinet. Inconsistencies were observed in drugs records. To protect residents’ wellbeing, and to ensure that there is an audit trail for medication, the following recommendation is made. The controlled drugs records and stocks are to be checked daily by the senior person on duty and signed for as being in order. Residents’ diversity is respected in the care planning process, which supports their independence and dignity through reviewing their care needs and the support, which they receive. For staff guidance, there are policies on privacy and confidentiality and staff, who were spoken with, were aware of the ways by which residents’ privacy and dignity will be respected in care giving. A resident said, “This place has been a life line for me. I fill my time as I please without interference but they are there if I need them. They couldn’t be more helpful and always polite.” Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The lifestyle in the home is relaxed and there is good community contact however, monitoring of activities and levels of satisfaction with meals will assist in improving the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. There is an activities co-ordinator in this home, and outings are arranged, the most recent being a trip out to a local restaurant. One of the residents said he goes out to the shops by taxi. Another said, “I keep in touch with my friends, I still get out and about, I like to stay in my bedroom mostly, and I have the television and newspaper to keep me occupied.” Some of the residents made use of local nearby local amenities and some go on holiday with family and friends. Residents’ beliefs are recorded in their care plans and their spiritual needs supported through visits from local ministers and priests. There is a range of opinion, abilities and needs regarding socializing and leisure, amongst the residents of Sandley Court. A number have become physically and mentally frail, whilst others are alert and ambulant. Residents’ Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 13 comments in quality questionnaires would suggest some improvements will be needed in relation to the frequency and types of activities on offer. To ensure that all residents have ongoing social support from staff, a recommendation is made their preferred activities and participation in them is recorded on their care plans. There was a relaxed atmosphere in Sandley court during the visit, residents were spending time in the lounges or in their bedrooms and visitors were being entertained in private. A visitor said, “I come here about once a week and enjoy it. I know that (Name) is looked after and I have not had cause to complain. Staff come in to bring us a drink but otherwise we are undisturbed. They are very considerate.” Residents are given information about Sandley Court in the service user guide and residents’ charter, which inform them of their rights and responsibilities and the choices available to them. They (or their representatives) are involved in planning their care and those who have no family have access to advocacy services. Residents confirmed that there are no set routines in Sandley Court and there is flexibility in mealtimes and rising and retiring times. There is a pleasant and well-presented dining room, which is next to the kitchen. There is a varied and seasonally reviewed menu with choices and alternatives on offer. Some of the residents said that although the food is well cooked, the quality has deteriorated recently. One resident said, “The meat is sometimes tough.” Another said, “The food is not as good as it used to be.” To ensure that residents’ food is to their satisfaction, it is recommended that consultation with them is ongoing regarding the quality and content of their meals. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. Residents’ complaints are listened to and they are protected by procedures and training in Sandley Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 and 18. Residents and their representatives are given a copy of Sandley Court complaints procedure, which clearly written, explaining the process and timescales for complaints investigations. There have been no complaints to CSCI about this service since the last visit. Sandley Court has procedures for protection of vulnerable adults and “whistleblowing” and staff have received training. Those who commented were aware of the indicators of abuse and of the procedures to be followed if abuse of a resident is suspected. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. The building is clean, comfortable, well maintained and suitable for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19, 26. The building is well maintained and furnished and decorated in a homely and comfortable style. The garden is attractive and well looked after with grassed and planted areas and a pond, which is stocked with fish. There are lounges on the ground and upper floors, a ground floor dining room and bedrooms on all floors. There is a passenger lift to upper floors and a ramp at the front entrance. Moving equipment is in place for residents who are frail and need assistance. Residents said they were comfortable and their bedrooms are personalised with ornaments and photographs of loved ones. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 16 In some of the upper floor bedrooms, television reception was said to be poor on some channels. A recommendation is given that remedial work be carried out to regain good reception as two residents said poor reception an ongoing inconvenience. A resident said she finds her bedroom very comfortable but the window was ill fitting and sometimes lets in drafts. To ensure comfort and safety, a recommendation is given that this window is fixed and the draft eliminated. The building was clean and residents said they were satisfied with the condition of their home. Visitors also confirmed that they have always have found the building to be clean. Domestic staff are employed and for their guidance there are procedures for infection control and the control of substances hazardous to health. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. Residents are protected through the recruitment and training procedures in Sandley Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. Sandley Court maintains a staff roster and that for the day of the visit was a true representation of staff who were on duty. The manager said that over 50 of staff have NVQ qualifications and a number are in the process of taking NVQs. The training schedules record mandatory training and updates either carried out or scheduled in the current year. The manager confirmed arrangements for formal supervision sessions with staff and for their appraisals. Staff said they were well supported by the manager and confirmed the training they have undertaken in recent months. Sandley Court has a recruitment procedure, which includes taking up references and criminal records bureau clearances for staff before they commence employment. A sample of staff files was read and these had been satisfactorily maintained. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. Sandley Court is managed in residents’ best interests however, improved risk management will protect residents who lack awareness of hazards to their safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31, 33, 35, 36, 38. Mrs. Marie Heslin is the appointed manager and has applied for registration with CSCI. She has several years of experience as deputy manager of Sandley Court. Mrs. Heslin has registered manager’s award and is undertaking NVQ level 5 in Management and Leadership. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 19 Sandley Court has a quality assurance system, which is based on seeking the views of residents and their representatives. A sample of the most recent quality questionnaires completed by residents was read. Mrs. Heslin said that remedial action is taken regarding any negative feedback in questionnaires, and positives are built upon. The manager confirmed that residents or their representatives are encouraged to manage their own financial affairs without the involvement of staff from Sandley Court. In instances where purchases may be may on a resident’s behalf by staff, expenditure is recorded and audited, and receipts are retained. Staff said they they are well supported by the management team and that they receive regular supervision (one to ones). Staff appraisals are carried out to ensure their training is up to date and to support their personal career development. There are systems in the home to manage environmental risks, a record of accidents is maintained and staff are trained in first aid, as stated in training records. To ensure residents safety whilst in the garden, a recommendation is given that risk assessments are carried out in relation to the pond, and the cellar steps and any identified remedial action taken. To ensure that residents are protected in case of fire, relevant tests are carried out to the fire system and equipment and the supporting records were in good order at the time of this visit. Health and safety certification was up to date regarding, gas electricity and servicing of equipment in Sandley Court. The food storage areas were clean and well organised, chilled and frozen food was labelled and dated and catering records were satisfactory. The laundry was clean and well organised and equipment was in working order. There are systems in place for the control of infection, staff have received relevant training and there are procedures in place for their guidance. Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 20 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations To ensure there is an accurate audit trail for medicines received into the home, the controlled drugs records and stocks are to be checked daily by the senior person on duty and signed for as being in order. To ensure that all residents have ongoing social support from staff, a recommendation is made their preferred activities and participation in them is recorded on their care plans. To ensure that residents’ food is to their satisfaction, it is recommended that consultation with residents is ongoing regarding the quality and content of their meals. To ensure that the building is well maintained, attention to be given to the window in one bedroom (as discussed) regarding the draft and difficulty with opening this window. 2. OP12 3. OP15 4. OP19 Sandley Court Care Home DS0000069299.V346230.R01.S.doc Version 5.2 Page 22 4. 5. OP19 OP38 Remedial work should be carried out to ensure satisfactory television reception in bedrooms. To ensure residents’ safety whilst in the garden, a recommendation is given that risk assessments are carried out in relation to the pond, and the cellar steps and any identified remedial action taken. 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