Inspection on 18/08/05 for Sandmartins

This inspection was carried out on 18th August 2005.

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

Sandmartins 21/11/08

Sandmartins 22/11/06

Sandmartins 01/02/06

Sandmartins 18/01/05

Sandmartins 18/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandmartins Kings Parade, Aldwick Bognor Regis West Sussex PO21 2QY Lead Inspector Annie Taggart Announced Thursday 18 August 2005, 11:00am th 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 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. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sandmartins Address Kings Parade, Aldwick, Bognor Regis, West Sussex, PO21 2QY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01243 864031 Homebeech Limited Mrs Pauline Pink Care Home 14 Category(ies) of PC Care Home only 14 registration, with number of places Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 18/1/05 Brief Description of the Service: Sandmartins is a care home registered to provide care for fourteen residents in the category of old age, not falling within any other category. The property is a large detached building, situated in a quiet residential area, just off the seafront at Bognor Regis. Accommodation is provided across two floors, communal space consisting of a lounge area, dining room,sun lounge and a large garden to the rear of the building. The registered provider is Homebeech Limited, the responsible induvidual is Mrs. S. Ellis and the registered manager is Mrs. P. Pink. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place at 11am and lasted for 4.5 hours, which covered the early and late shifts at the home. During the course of the visit the inspector spoke to all of the people living in the home and held longer conversations with nine residents. Three staff members and a visitor to the home were also spoken with and a complete tour of the home was undertaken. Five care plans and five staff files were seen including risk assessments and training records. Health and safety and maintenance records were also seen and the inspector spent time with residents over the lunchtime period. Prior to the visit, the last two inspection reports were read, along with any other correspondence and documentation relating to the service. A pre-inspection questionnaire has been completed by the service and this document was also used to inform the visit. Six relative/visitor comment cards were returned and all made positive comments about the home. The responsible individual Mrs. Ellis and the registered manager Mrs. Pink were present in the home and assisted with the inspection. What the service does well: The home provides a comfortable, attractive and well- maintained environment for the people who live there. Residents in the home say that they are very happy there and that the staff team are kind and caring. There are a variety of activities available to provide interest and stimulation for residents. The people living in the home say that they are treated with dignity and that their lifestyle choices are respected. There is a core staff team who have worked at the home for a number of years and have built up good relationships with the people they support. Residents and visitors to the home are very complimentary about choice of food provided. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 6 The home is managed by a competent and caring manager and records are well kept. 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. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 standard(s) 1 2 3 4 5 6 Residents and there families receive sufficient information to inform them about the facilities available in the home. Pre-admission assessments are completed and visits to the home encouraged. EVIDENCE: There is a Statement of Purpose and Service User Guide available, which set out details of the accommodation and facilities available in the home. Both documents have recently been reviewed and updated. The manager of the home carries out comprehensive pre-admission assessments either in hospital or in the resident’s’ own home in order to ensure that the home can meet individual needs. Prospective residents and their families are encouraged to visit the home to meet the people living there and to stay for coffee or a meal. Each new resident receives a contract detailing the terms and conditions of occupancy, these documents have also been updated and in consultation with residents and their families are to be reviewed on an annual basis. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 9 Residents confirmed that they had visited the home before moving in and a visitor said they had chosen the home from many visited because it was “small and friendly”. Sandmartins does not provide intermediate care. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 standard(s) 7 8 9 10 11 Care plans are in place, which set out the health and social care needs of each person living in the home. Residents are treated with dignity and respect and wherever possible can stay in the home until the end of their lives. EVIDENCE: Care plans are in place, which set out the health and social needs of each person living in the home. The documents contain comprehensive information designed to inform the staff team about the way each person wishes to be supported and include risk assessments, likes and dislikes medical conditions and food allergies. There is evidence of input from a variety of health professionals including district nurses, occupational therapists and doctors and assessments are carried out with regard to risks to pressure areas. The plans have been agreed and signed by the resident or their representative and are reviewed and updated on a regular basis. There is an agreement in place with a local pharmacist and a monitored dose system is used to administer medication. The storage and administration of medication was in good order but several gaps were found in the signing of the Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 11 medication recording sheets. All staff members administering medication have received accredited training, but in order to ensure that residents are protected at all times, the training and procedures should be reviewed. Whenever possible residents can stay in the home until the end of their lives and last wishes are recorded in the care plan. If people need to be moved to a nursing home families are involved and supported through the process. The manager and staff members attend funerals whenever possible and there are cards and letters on file from families thanking the staff for their kind and sensitive care. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 standard(s) 12 13 14 15 There are a variety of activities available to offer stimulation and interest to residents. Visitors are made welcome and the food provided is of a high standard. EVIDENCE: Residents said that the home met their needs and that they were encouraged to be as independent as possible. One person said, “We are always given a choice and I have the freedom to do what I want. Another resident said “I go to bed when I want, have tea in the garden or just go for a walk”. A programme of activities is posted in the home and includes, visiting musicians, keep fit, flower arranging and bingo. There are books and magazines around the home and during the afternoon there was a keep-fit session. Residents were knitting, reading or sitting in the garden and two people were playing scrabble. Staff members were setting up bunting for a garden party to be held the next day and residents were really looking forward to the event. A visitor to the home confirmed that they were always made welcome at any time and said that they were kept involved with the care of their family member. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 13 The inspector spent time with residents during the lunch period and observed interactions with staff members. The home has a four- weekly menu in place and there is always an alternative choice at each mealtime. Lunch consisted of fish, chips and peas or an alternative of home made pasty and vegetables, with steamed pudding or cheese and biscuits to follow. Residents in the home spoke highly of the new chef and said that the food was very good. One person said “I am always given a choice, sometimes I need to be fed and there is always someone there to help me”. The chef said that vegetarian, diabetic and pureed foods are available and other diets could be catered for if required. The mealtime was unhurried and residents had a choice of where they ate. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 18 Residents and their families can be confident that their concerns and complaints will be acted upon. The home has a whistle-blowing policy in place but all staff members need to attend adult protection training. EVIDENCE: There is a complaints procedure in place a copy of which is included in the Statement of Purpose and Service User Guide. A copy of the procedure is also posted in the home. Four complaints have been recorded in the last twelve months. All have been dealt with in a satisfactory manner by the manager of the home. Residents said that they felt comfortable in speaking to the manager or a staff member if they wished to complain and said that they were sure their concerns would be listened to. Accidents and incidents are recorded and the relevant documentation sent to the Commission as required. The home has a copy of the West Sussex Adult Abuse policy and also has a “whistle blowing” policy in place. Staff members spoken to are aware of their responsibilities should they suspect abuse had taken place. To ensure the protection of residents at all times it is a requirement that all staff members attend training in the protection of vulnerable adults from abuse. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 21 22 23 24 25 26 The home provides a comfortable and attractive environment for the people who live there. Communal facilities and private bedrooms are homely and well maintained and the building is very clean and hygienic. EVIDENCE: There is an attractive, light and airy lounge and sunroom available, which are furnished and decorated to a high standard. The dining room is also very pleasant and is and easily accessible. The large rear garden is landscaped with trees flowers and shrubs and has areas for people to sit. There are sufficient bathing and toilet facilities available including assisted baths with hoists. Raised toilet seats and other equipment such as hand and grab rails are in place to aid mobility and increase independence. Where necessary the district nurses provide specialist pressure relieving mattresses and chair cushions and all equipment is well maintained. During the last year the programme of covering radiators has been completed, the lounge has been redecorated, some new carpets, a cooker and fridge/ Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 16 freezer have been purchased and the downstairs bathroom has been refurbished. Private bedrooms were also decorated in an attractive manner and all rooms have been personalised with belongings brought to the home by residents. As rooms become vacant they are completely refurbished before being reoccupied. Residents said that they were very happy with their rooms and people said that they liked living in the home because it was small and felt “homely”. Anti-bacterial hand cleaners, gloves and aprons are available for the use of staff and the home was very clean and hygienic. There are four CCTV cameras in place one of which overlooks the lounge area. The manager of the home said that during good weather the patio doors at the front of the house are open so that people can sit out. The cameras can pick up if intruders enter the house or if a resident wanders or falls. There is no sound attached to the cameras. The manager has completed risk assessments in order to identify areas which could be seen as an invasion of privacy within the home and residents can use their rooms or the dining area to see visitors in private. Consideration should be given to including a statement about the use of CCTV in the information packs given to prospective residents and their families. A large wooden structure has been erected at the end of the garden and will soon be turned into the office for the home. A building plan is in place to make changes to the kitchen in order to make a path available to the laundry and office without having to go through the kitchen. At the present time a risk assessment is in place in respect of laundry, which staff members now take around the outside of the house. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 30 There are sufficient staff members available to meet the assessed needs of the current residents in the home. A robust recruitment procedure is in place and staff members have access to training and support. EVIDENCE: At the time of the visit there were twelve residents living in the home. There were three carers, the manager and a cook on the day shift and two people are employed at night, one awake and one asleep. No other ancillary staff are employed in the home and the care staff also carry out cleaning and laundry duties. The manager of the home said that should the needs of the current residents increase, a staffing analysis would be carried out to ensure sufficient numbers are made available. Residents said that there were always staff available to offer them support when needed and staff members said that their working day provided enough space to spend “quality time” with the people they support. Robust recruitment procedures are implemented before new staff members are employed. Five staff files were seen by the inspector all were in good order included two references, evidence of an interview process and a criminal bureau check. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 18 New staff members receive an induction programme in line with current guidelines and have access to a variety of training courses. Staff records show evidence of attendance at courses including mandatory training, medication, infection control, dementia awareness, the Diploma in Care and currently 50 of the staff team hold NVQ2 or above. The home also provides English language lessons for staff from other countries. Staff said that they enjoyed working at the home and said that the atmosphere is friendly and supportive. Residents spoke very highly of the staff team and said that they were very kind and caring. One person said, “The staff are excellent and if I ring in the night, someone will always make me a cup of tea”. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 33 34 35 36 37 38 The home is run by a competent and caring manager who attends ongoing training in order to update her skills and knowledge. Policies and procedures are in place with regards to health and safety and records are in good order. EVIDENCE: The registered manager has completed NVQ4, the Registered Manager’s award and attends additional training in order to further her knowledge and skills. Both the people living in the home and staff members spoke very highly of Mrs. Pink and said that she was kind, caring and very supportive. Comment cards received from relatives/visitors to the home were also very complimentary and said that the home was run in the best interests of the people living there. One person said,” My mother is well cared for, she is happy at Sandmartins, which is a caring home. It is clean, bright and cheerful with good food and excellent staff”. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 20 Staff confirmed that they receive supervision sessions, which includes good practice topics on a regular basis and records are kept on file. The registered provider, Mrs. Ellis confirmed that a financial plan is in place for the home, which covers an ongoing programme of replacement and redecoration. Where Homebeech Limited acts in respect of resident’s finances, this is organised centrally at the head office of the organisation and kept in separate bank accounts. Individual spreadsheets are kept which are independently audited. Lockable facilities are available in bedrooms to ensure residents can manage their own money should they wish to do so. Small amounts of personal monies are kept at the service with all transactions being recorded. One person’s money and records was checked and found to be correct. A quality assurance system is in place to ascertain feedback from residents, families and other professionals involved with the home. Recently the manager of the home arranged a cheese and wine party for residents and their families in order to receive feedback and ideas in a more informal setting. Records were seen including the insurance policy, maintenance checks, fire, gas, electrical checks and the environmental health report. All were current and in good order Residents are protected by policies and procedures being in place in respect of health and safety. Mrs. Pink has completed detailed risk assessments for both residents and the environment and the quality of these assessments is to be commended. The registered provider said that an independent health and safety audit is to be carried out on the building in the near future in order to improve facilities and review and update corporate policies. As previously stated gaps were found in the medication recording, which has resulted in a requirement being made. Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 2 3 3 3 3 3 3 3 3 Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13 Requirement Staff training should be reviewed to ensure procedures are followed in respect of medication recording sheets. All staff at the home should attend training in the protection of vulnerable adults from abuse. Timescale for action 30th October 2005 30th November 2005 2. OP18 13 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 Good Practice Recommendations Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 Sandmartins H60-H11 S44061 Sandmartins V236310 180805 Stage 4.doc Version 1.40 Page 24 - 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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