Inspection on 02/06/05 for Sandon House

This inspection was carried out on 2nd June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sandon House 11/04/07

Sandon House 16/12/05

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 2nd June 2005 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. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sandon House Address Market Street, Mossley, Tameside, OL5 0JG 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) 01457 834747 Tameside Care Limited Mrs Irene Booth CRH - Care Home 38 Category(ies) of DE(E) Dementia - over 65 (38) registration, with number OP Old Age (38) of places PD(E) Physical Disability - over 65 (26) SI(E) Sensory Impairment - over 65 (1) Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 5th February 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 Tameside Care Limited, a not for profit organisation, which operates several other care homes in Tameside. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection six service users were interviewed, as were four relatives of service users. Additionally, discussions took place with the manager. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records, as well as other documentation, including staff rotas, medication records and the complaints log. This inspection was unannounced and not all the standards were assessed. What the service does well: What has improved since the last inspection? Several aspects of record keeping and administration had improved. These included clarity about the procedures for the Protection of Vulnerable Adults and the administration of medication. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 6 The vetting procedures for new staff were more robust, which has improved the home’s ability to protect the interests of service users. Activities were more appropriately publicised in the home, making them more accessible to more service users. 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. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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) 2, 3 & 5 The home provided terms and conditions for each service user. Service users had their needs assessed before moving into the home. People were encouraged to visit the home before making a decision to move in. EVIDENCE: A small sample of service users’ files was scrutinised. All had a copy of the home’s terms and conditions which had been signed by the service user. There were copies of assessments undertaken before any service user moved into the home, in order to ascertain whether or not the home could meet the needs of the service user. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 9 The home had a written policy of encouraging service users, or their representatives, to visit the home before making a decision to move in. All relatives who were asked, confirmed that they had visited the home before their relative moved in, to establish if the home was suitable. Several people mentioned the importance of Sandon House being located in Mossley, and the consequent maintenance of links with the community. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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) 8, 9 & 10 Service user health needs are appropriately met at the home. The home’s policies, procedures and practice work to serve the best interests of service users in connection with the administration of medication. Service users are treated with respect and dignity, with their privacy respected. EVIDENCE: All service users and visitors spoken to expressed confidence that appropriate medical and paramedical support was obtained when necessary. A visiting optician reported good communication with the home and that, in their opinion, appropriate referrals were made. There was also documentary evidence of the involvement of medical personnel attending service users at the home. Daily records were seen which demonstrated that appropriate observations were made when a service user was not well, to inform the decision to seek medical support. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 11 Sandon House used the Nomad pre-dispensed monitored dosage system of medication administration. Medication was seen to be stored appropriately and the medication administration records presented as being appropriately maintained to accurately record the frequency and amount of medication given to each service user. It was reported that the pharmacist visited the home to offer advice and guidance on a three monthly basis. It was reported by the manager that, at the time of this inspection, no service user was administering their own medication, although, subject to an assessment of any potential risk, service users could do so. All bedrooms were single, which is an aid to privacy, and service users spoken to confirmed that they could use their room at any time. One visitor confirmed that their relative preferred to spend most of their time in their room, and this was respected by the staff. Each room had a lock and the manager reported that many service users held their own key. Documentary evidence was seen of the reason why a service user did not want a key to their room. Discussion with the manager and observation indicated that service users were treated as individuals. Consequently, ‘banter’ between staff and some service users was not apparent with service users who would not appreciate that level of informality. One visitor said of Sandon House – its “called a ‘Care Home’ and that is what it does, care in the fullest sense of the word.” Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 Service users experience a positive lifestyle and can exercise choice and control over their lives, within the confines of communal living. The home encourages visiting and the maintenance of community contacts. The home provides good food. EVIDENCE: A range of activities were available in the home on a regular basis. These were publicised on the notice board and included: board games; quiz nights; crafts; aromatherapy; bingo; memories are made of this and occasional video nights, chip supper, outings and trips. Structured Records of as a result the service service user meetings were held approximately four times a year. these were maintained which demonstrated that the actions taken of the previous meeting were checked to ensure the outcomes for users were as expected. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 13 Service users spoken to were able to confirm the availability of these activities and meetings. One visitor wondered if more entertainment might improve the quality of their relative’s experience as dementia inhibited their ability to participate in many activities. Sandon House has a policy of encouraging visiting. All visitors spoken to confirmed that they were able to visit at any reasonable time. Visitors experienced communication with the home as being good. This, as with the home’s response to service users, presented as being sensitive to the needs of the individual relatives. Consequently, one relative said “[they will contact me] with the slightest worry”, while another really appreciated the ‘permission’ the home gave them “… not to be here all the time … [they] sort things out without bothering me.” All service users reported very positively on the attitude of the staff team and their ability to exercise choice and control over their lives, given the restraints of communal living. One reported that “I’ve been here six years and if I hadn’t of liked it I’d be elsewhere.” Another said “[it is] better than being on my own at home … [they] can’t do enough for you.” Another service user told the inspector that one of the best things about Sandon House was the “freedom to do what you please”. No meal was sampled at this inspection. However, all service users spoken to reported positively on the meals at Sandon House. One service user said they had “enjoyed every meal”, others described the food as good, with one service user and one visitor citing the food as amongst the best things about the home. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 The home would deal appropriately with any complaints or concerns. Service user were protected from abuse or exploitation. EVIDENCE: The home had an appropriate complaints procedure. A record was maintained of complaints made, together with the outcome of the complaint and any action taken. All service users and visitors spoken to were confident that they could talk to the staff about any complaint that they may have and that their views would be taken seriously. The home has a procedure for the protection of vulnerable adults, including a procedure for contacting statutory agencies if the home or the Company fail to address unsafe practice. All service users and visitors spoken to expressed the view that all service users were ‘safe’ in the home. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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, 23 & 24 The home was appropriately maintained and clean and tidy throughout. Communal areas, both inside and out, presented as being safe and comfortable. Suitable bathing and toilet facilities were available for service users. Service users’ bedrooms were appropriately personalised. EVIDENCE: During the inspection a tour of the building was undertaken, including a selection of service users’ bedrooms. No issues requiring remedial work were identified during this tour. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 16 The home presented as clean, tidy and appropriately maintained. This was an unannounced inspection and service users and visitors all confirmed that the home was always clean, with no unpleasant odours. Service users’ bedrooms were well decorated and there was an appropriate variation in the personalisation of the rooms. Service users spoken to said that they liked their rooms. The communal living areas presented as well maintained and comfortable. The was a pleasant enclosed garden area at the home. Service users reported enjoying the garden in the pleasant weather. There were appropriate bathing and toilet facilities. At the time of this inspection one bathroom was being refurbished. There remained sufficient bathing facilities while this work was being undertaken. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 The home provided an appropriate number of appropriately qualified staff. The home operated an appropriate recruitment and vetting procedure to protect the interest of the service users. EVIDENCE: The staff rota for the week beginning 23rd May 2005 was examined. This demonstrated that staffing was usually maintained at five carers between 07:00 and 20:00 and two carers at night (20:00 – 07:00). There were exceptions to this and, on occasions, there were between six and eight care staff on duty. Following the previous inspection the manager had reviewed the staffing levels and was satisfied that appropriate cover was provided at all times. As stated elsewhere in this report, all service users and visitors were very positive about the staff team. Comments included – “staff are very good. If you need anything you just ask and they sort it out.”, “very obliging and nothing is too much trouble”, “very good staff” “treated very fairly” “ [they] take good care of my mum and her things” “staff are smiley”. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 18 It was reported that no new staff had commenced work since the previous inspection, although two were waiting to start pending the completion of the vetting procedures. Inspection of one file relating to one applicant indicated that appropriate vetting was in progress. The manager reported that of the 20 care staff, 11 had NVQ II and one of those also held NVQ III. This represents 60 of staff with NVQ II or higher. A selection of NVQ certificates were checked to verify this. Additionally, a further five staff were enrolled on the NVQ II course. It was reported that staff were offered a range of other in-house and external training and that Tameside Care Limited was maintaining its commitment to staff training. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 The manager is effective in her role. The ethos of the management of the home is for the benefit of the service users. Outcomes of the quality audit and quality monitoring process are not communicated to the service users. EVIDENCE: The manager holds an appropriate qualification in management and care. During the inspection she demonstrated a good understanding of the role and responsibility of a manager. Similarly, her understanding of the needs of older people presented as being thorough. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 20 Service users and visitors spoke very positively about the attitude of the manager and other members of the management team. Comments included “a very good manager”, “[the manager and deputy are] brilliant”, “the most understanding person I’ve met”, “absolutely brilliant”. Service users spoken to were confident that their views would be taken into account in the running of the home. Regular service user meetings were held and the minutes of those meetings indicated service users’ ability to influence the agenda and to make constructive suggestions about the running of the home. As at previous inspections, quality audit and quality monitoring systems were in place. These included effective open communication, questionnaires and meetings. However, these have yet to be structured in such a way that a report is compiled and made available for service users and prospective service users. The production of such a report would further enhance the open approach of the home and further enhance the opportunity for service users to influence the future running of the home for their benefit. Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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 x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 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 3 3 3 x 3 3 x x STAFFING Standard No Score 27 3 28 4 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 2 x x x x x Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 22 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. Standard 33 Regulation 24 Requirement The registered person must ensure that a quality assurance and monitoring system is in place which enables an effective measure of the services on offer at Sandon House. A report of the monitoring must be made available. (Timescale of 01/05/05 not met). Timescale for action 01/09/05 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 Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton under Lyne OL7 0QD 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 Sandon House F54 F04 5579 Sandon Hse v225589 020605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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