Inspection on 11/04/07 for Sandon House

This inspection was carried out on 11th April 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

Sandon House 16/12/05

Sandon House 02/06/05

Sandon House 05/02/05

Sandon House 08/06/04

Sandon House 05/02/04

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 Sandon House Market Street Mossley Tameside OL5 0JG Lead Inspector Steve Chick Unannounced Inspection 11th April 2007 10:00 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 Sandon House DS0000005579.V334158.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. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandon House Address Market Street Mossley Tameside OL5 0JG 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) 01457 834747 01457 839996 sandon@tamesidecg.co.uk Meridian Healthcare Ltd Mrs Irene Booth Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Physical disability over 65 years of age (26), Sensory Impairment over 65 years of age (1) Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 38 OP, up to 38 DE (E), up to 26 PD (E) and up to 1 SI (E) One named person under 65 years. Date of last inspection 16th December 2005 Brief Description of the Service: Sandon House is a two storey, detached, purpose built care home situated in the centre of Mossley, with easy access to the local shops and facilities, as well as public transport links to Ashton under Lyne. It offers accommodation to up to 38 older people, all in single rooms. Sandon house has three lounge/dining rooms, a dedicated smoke room and an outdoor garden area for communal use. The home is run by Meridian Care Limited, a not for profit organisation, which operates several other care homes. At the time of this report fees were reported as ranging from £361.75 to £381.75. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection four service users were interviewed in private, as were five relatives of service users and two other visitors to the home. Additionally discussions took place with the manager and deputy manager and three staff members were interviewed in private. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and some maintenance documentation. This key inspection included an unannounced site visit to the home. All key standards were assessed. This report also uses information gathered since the previous visit and information provided by the manager. All service users and visitors spoken to were positive about the care offered at Sandon House. One visitor, when asked what the ‘best thing’ about the home was, replied “it’s a well run home, … consistent staff, ..can visit any time and are welcomed.” Another described the home as “a very good place, I wouldn’t mind living here myself”. What the service does well: What has improved since the last inspection? The manager has addressed the outcome of the latest quality audit in a more structured manner. The good quality of care for service users has been maintained. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 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 Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. Service users’ needs are appropriately assessed before moving to the home, to ensure that their needs can be appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service users’ files was looked at. All service users who had recently been admitted to the home had documentary evidence on file, of assessments being undertaken by appropriate professionals in the community. There was also documentary evidence that the home undertook its own assessment to complement that provided by external agencies. Sandon House has a written policy which encourages prospective service users, or their representatives, to visit the home before making a decision to move in. Relatives who were spoken to confirmed that a positive choice had Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 9 been made for their relative to move to Sandon House, following the opportunity to visit having been taken up. Sandon House does not offer intermediate care. Sandon House DS0000005579.V334158.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): 7,8,9 and 10. Quality in this outcome area is good. Service users’ health, personal and social care needs are met by the consistent implementation of the home’s policies and procedures. Staff practices also serve to promote the dignity of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service users’ files was looked at. All had written plans of care and there was documentary evidence that these had been regularly reviewed. There was also documentary evidence to confirm that service users, or their representatives if appropriate, had signed to confirm their agreement with the written care plan. Relatives who were asked, confirmed that they were involved in discussions about the nature of the care provided for their relative. For example, one visitor was able to cite an occasion where their relative was Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 11 wearing pop socks which they did not feel was appropriate. This was mentioned once and they have never been worn again. All visitors spoken to were positive about the care offered at Sandon House, as were all service users spoken to. Discussion with the manager and staff indicated that all service users are related to as individuals. One staff member described Sandon House as like a big family, we know everybody and their relatives. Another staff member commented Sandon House is small enough to be intimate, in so far as you can build up relationships with service users. One relative expressed the view that, from their observation of the way in which staff relate to all service users, the character of each person is known by each staff member. All service users and visitors who were asked, expressed a high level of confidence that appropriate medical support is sought when necessary. There was documentary evidence which presented as being a good record of service users contact with medical professionals. One visiting professional described Sandon House as one of the best homes they had worked with. They reported that they were appropriately contacted and that Sandon House staff followed instructions given by medical personnel. The policies and procedures relating to medication had been found to be appropriate on previous visits. Information from the pre-inspection questionnaire indicated there had been no change and consequently these procedures were not looked at. The home uses a pre-dispensed monitored dosage system to administer service users’ medication. Medication was seen to be appropriately and securely stored. A sample of medication administration records was looked at, which presented as being appropriately maintained. At the time of this visit, the manager reported that no service user was administering their own medication, although, subject to a risk assessment, they could. Observation and discussion with service users and visitors, indicated that service users are treated with respect and that their dignity was maintained. Interactions between staff and service users presented as relaxed, with assistance and support being offered in a sensitive manner. One member of staff gave as an example of treating service users with respect, the importance of engaging with, and talking to, service users who need assistance with eating. Sandon House DS0000005579.V334158.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): 12, 13, 14 and 15. Quality in this outcome area is good. An appropriate range of activities was available for service users, and visitors are welcome in the home, which enhances service users fulfilment and social stimulation. The provision of food to maintain service users’ health and well-being is good and service users are able to maximise their autonomy within the context of communal living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives who were spoken to confirmed that Sandon House had been chosen following visits and comparison with other care homes. Many, although by no means all, service users previously lived in the locality. The manager confirmed that the good community links which have been identified at previous visits have been maintained. These include links with local churches and the local community hall which, for example, offers priority tickets for dramatic and musical events. A visiting professional talked about Sandon Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 13 House being a home for the community, where people know each other. During the tour of the building the manager reported that a bench was to be purchased for a small patio area as a new service user had enjoyed sitting outside their house, watching the world go by, before moving to residential care. A range of activities was reported as being available for service users to participate in if they wished. The daycare centre, attached to Sandon House, had recently closed down. On previous visits this had been found to offer a good range of activities on a daily basis which residents at Sandon House could take part in. The manager and senior staff reported that they were looking at ways to ensure staff continue to have sufficient time to engage in activities with service users. Regular activities on offer at the time this visit were reported as including an aromatherapist on a weekly basis, celebration of various festivals, occasional visits from entertainers and outings. One member of staff reported having taken part in an equality and diversity distance learning programme. She reported that this had reinforced the need not to stereotype and cited as an example the fact that not all older people dislike modern music. All service users and visitors spoken to confirmed that there were no unreasonable restrictions on visiting. Visitors are made to feel welcome and reported good communication with the home. Two visitors reported that they valued the fact that the home had encouraged them to use the facilities, for example, to make themselves cups of tea or coffee. Service users reported that there was freedom of choice in terms of when they got up and went to bed etc. Observation and discussion with staff and service users confirmed that people can choose to stay in their own rooms or use one of the communal areas. The manager also reported that some service users prefer to take their meals in their own rooms and this is enabled. The person centred ethos of the home served to underline the importance of individuals making choices about their lives within the inevitable restrictions of communal living. All service users reported positively on the provision of food at Sandon House. During this visit one meal was sampled which was pleasantly presented and tasty. Visitors also commented favourably on the provision of food for their relatives. Service users confirmed that a choice was available. One service Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 14 user said one day I fancied poached egg on toast instead of the meal on offer and she did it without any problems. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is good. Service users and relatives are confident that any complaints they may have would be dealt with appropriately. Service users are protected from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sandon House has an effective complaints policy which has been inspected on previous occasions. The documentation was reported as not having been amended since the last inspection and was not looked at on this occasion. All service users and relatives spoken to during this visit expressed the view that any complaints they may have would be responded to appropriately. Staff were described as easy to talk to. One visitor reported that if youve got a question you always get an answer, a good response and good Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 16 communication … [their relative] had always said she was never frightened to ask for anything. The record of complaints was looked at. While only three complaints had been recorded the documentation presented as being appropriately maintained. All service users and relatives spoken to during the visit expressed the view that service users were protected from abuse and exploitation. When asked, two relatives said that in their opinion service users were totally safe. One service user when asked if he felt safe at Sandon House replied safe as a row of houses -- and that is very safe. Staff who were spoken to demonstrated an understanding of the need to be vigilant to protect vulnerable service users from abuse and exploitation. Most staff spoken with had received training in connection with the protection of vulnerable adults. All staff indicated that they understood the whistleblowing policy of the company. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this visit a tour of the building was undertaken, including a selection of service users bedrooms. No issues requiring remedial work were identified during this tour. Apart from the internal communal areas there was a pleasant, secluded, garden area which was reported by the manager as being well used in pleasant weather. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 18 Service users bedrooms demonstrated an appropriate level of personalisation, and as with the rest of the home, were clean and well maintained. The company had written to the Commission for Social Care Inspection as there were plans to extend the building. This would inevitably mean some disruption to service users, but discussion with the manager indicated that planning had been undertaken to minimise this. At the time of this visit the home presented as clean and tidy throughout with no unpleasant smells. All visitors and service users spoken to confirmed that this was the usual state of the building. One service user described the standards of cleanliness as very good. One relative described Sandon House as having a nice feel, homely but pleasant and you feel very comfortable Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 and 30. Quality in this outcome area is good. The numbers and skills mix of staff on duty promotes the independence and well being of service users. Recruitment and vetting procedures are usually effectively applied to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the staff rota for the week ending 08/04/07 was looked at. This indicated that staffing levels were maintained at between five and six carers on duty during the day (07:00 -- 20:00) and two at night. These numbers exclude the manager and ancillary staff such as domestics and kitchen staff. It was reported by the manager that 14 of the 20 staff held NVQ II and 1 held NVQ III. Additionally two staff members were registered to commence the NVQ II course. A selection of certificates was looked at to confirm this information. At previous inspections the company had been found to offer a wide range of appropriate training. Both the manager and staff who were talked to, confirmed that this remained the case. Apart from the NVQ training staff were able to identify courses they had been on, such as equality and diversity, handling of medicine and palliative care. It was also confirmed by Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 20 staff and documentation, that all staff receive a period of induction. The deputy manager is a trained moving and handling facilitator. A selection of staff files was looked at in connection with recruitment and vetting procedures. These generally demonstrated that appropriate vetting, in line with legislative requirements, was thoroughly undertaken. However one example was seen where a full employment history was not held on file. Service users and visitors were all complimentary about the staff team’s competence and attitude. One service user described the staff as the best thing about home, and another reported that she had always been treated well at Sandon House its their mannerisms, the way they treat you. Relatives reported that the staff are absolutely excellent, brilliant with her and with us. Other relatives identified the very caring staff as the best thing about the home. One relative said I cant praise the staff enough. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 21 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, 33, 35 and 38. Quality in this outcome area is good. The manager is competent to run the home, use the quality audit systems and implement the health and safety procedures for the benefit of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has several years experience of managing a care home and holds an appropriate professional qualification. Service users, visitors and staff were all complimentary about her management style. Both she and the management team were described as approachable. One service user commented that the manager was one of the most understanding people I Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 22 have ever come across. Staff who were spoken to, confirmed that the manager, the management team and colleagues were all supportive. The company undertakes regular quality audits including periodic questionnaires to service users and their relatives. A report following such a quality audit in October 2006 was seen. This included an action plan written by the manager. There was some evidence that identified action was being pursued through, for example meetings with service users. A selection of records relating to money held by Sandon House on behalf of service users was examined. The records presented as being appropriately maintained. Receipts were obtained for purchases made for service users and the record was signed by the service user if cash was returned to them. At previous visits to Sandon House documentary evidence has been seen which demonstrated that the organisation consistently and routinely undertook appropriate checks in connection with health and safety issues and the maintenance of equipment. A small sample of documentation was looked at on this occasion. This all presented as being in order. The manager confirmed that measures to safeguard the health and safety of service users and staff are maintained. Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 23 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sandon House DS0000005579.V334158.R01.S.doc Version 5.2 Page 24 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 OP29 Good Practice Recommendations The registered person should ensure that a record is maintained of the explanation of any gaps in the employment history of all staff. This would enable the home to demonstrate full compliance with the regulations relating to recruitment, and to demonstrate their attempts to minimise service users being exposed to inappropriate staff. 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