Inspection on 13/10/05 for Sandridge House Nursing Home

This inspection was carried out on 13th October 2005.

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

The inspector 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

Sandridge House Nursing Home 14/08/08

Sandridge House Nursing Home 14/08/07

Sandridge House Nursing Home 23/05/06

Sandridge House Nursing Home 19/04/05

Sandridge House Nursing Home 16/11/04

Sandridge House Nursing Home 19/08/04

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

CARE HOMES FOR OLDER PEOPLE Sandridge House Nursing Home London Road Ascot Berkshire SL5 8DQ Lead Inspector Stewart Mynott Unannounced Inspection 13th October 2005 10:30 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 Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandridge House Nursing Home Address London Road Ascot Berkshire SL5 8DQ 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) 01344 624404 01344 874474 Amberbrook Limited ***Post Vacant*** Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom nursing care and accommodation is provided at any one time shall not exceed 25 (twenty-five) Up to 2 (two) service users within the overall registered numbers can be between the ages of 60 - 65 years. 19th June 2005 Date of last inspection Brief Description of the Service: Sandridge house is owned and managed by Amberbrook management Ltd, a private company, who are registered to provide personal care for up to 38 older people and nursing care for up to 25 persons. The property is a large old prestigious Victorian building that is situated in a prime location near to Ascot racecourse. Heatherwood Hospital and the premises of the primary care trust are also in the immediate vicinity. The home is clearly signposted and there is space for car parking on the site. Ascot village is close by and there is access to public transport. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during the day, which lasted for 6½ hours. The nurse in charge gave a tour of the premises, which covered all areas of the home. The remainder of this inspection was spent with service users and staff during which most service users and all staff on duty were spoken to. During this time the daily life of service users was observed. Four relatives and the visiting hairdresser were also spoken to gain their views. Records relating to the care of service users were focussed on during this inspection with some of the homes records examined in addition. Feedback was given to the group manager at the end of the inspection. What the service does well: What has improved since the last inspection? Requirements from the previous inspection were considered and evaluated against the action plan that had been sent in response by the Group Manager. All required action had been taken or was in progress. These improvements include better access for service users within the home and some reviews to the standards surrounding hygiene and control of infection. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Information is provided to prospective service users to help then choose the home. All service users have their needs fully assessed before moving into the home. Service users have been recently admitted with a clear diagnosis of dementia and the home is not registered to provide this type of care. EVIDENCE: During the inspection service users were spoken to who had moved into the home within the past year. Three service users confirmed that their needs had been assessed and one service users remembers the previous manager completing an assessment prior to admission. All three service users had not visited the care home before admission, as they were in hospital, however they did remember their relatives visiting before hand. Admission records for these service users were examined and detailed assessments were in place prior to admission from both the care management process and the previous manager. One relative confirmed that an assessment had occurred before admission both by the care management process and the previous manager had also visited. The relative confirmed that he chose the home on the basis of that the home Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 9 could cater for the persons needs according to information he had received from the home. Admissions records for the last two service users were examined and in both cases the assessments confirmed a diagnosis of dementia. One service user was spoken to and it was apparent that the service users dementia was fairly advanced. The nursing staff felt confident that they could cater for this persons needs. A relative and some service users commented that they felt the number of service users with a dementia has increased over time. The home would be required to demonstrate that they could meet the needs of service users with a dementia and apply to be registered for providing this service. The home is not currently registered to meet the needs of service users with a dementia and it is a requirement that service users with a diagnosis of dementia are not admitted. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Service users health and personal care needs are recorded in detailed care plans, which are kept under regular review. Service users health care needs are fully met. Service users are treated with dignity and respect at all times by a professional staff team. EVIDENCE: Several service users care records were examined. Each one contained a detailed plan of care, which clearly identified the needs for each service user. Two care plans for recently admitted service users were generated from pre assessment information. Care plans were sufficiently detailed including information on social and personal care needs. There were detailed information on health needs including assessments for nutritional screening, tissue viability, falls prevention and psychological health. Further risk assessments were kept which were individual to each service users needs and kept under regular review. Care plans and all documentation had been regularly reviewed each month by the senior nursing team. Service users spoken to were not directly aware that they had a care plan although assumed that detailed records were kept in relation to their needs. Five service users discussed their needs, which were accurately recorded in Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 11 care plans and other documents. Service users confirmed that they had been present at annual reviews to discuss their needs. Service users confirmed that they felt that their nursing and medical needs were well attended to by the nursing staff or GP, and all treatment occurred in private. Service users confirmed that there was full access to all local NHS facilities. During the inspection one serive users had a hospital appointment and was accompanied by a care assistant. Records were kept in relation to all GP and other health visits. One service users needs had changed recently. Care records demonstrated that this service user’s needs had been kept under constant review with alterations to care planning and risk management clearly identified. This service user has been referred for placement in a care home providing nursing and dementia care. During the inspection this service user often called out and could appear distressed at times. Staff were observed to attend to her in a kind and understanding manner. Service users spoken to were complimentary about the staff team and in all cases described the staff as “kind”, “caring”, “friendly” and “very good”. Service users confirmed that they felt treated with dignity and respect at all times. Service users also confirmed that their care is always carried out in private, they are addressed in their preferred term and all post arrives unopened. One service user described using the telephone in private. Relatives spoken to confirmed that they were happy with the care that was provided within the home and staff were always professional. Observation during the day revealed that staff always knocked before entering a service users own room and were professional and discreet in attending to service users needs. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Service users are able to maintain contact with their visitors and receive visitors as and when they wish. Service users are helped to exercise choice and control over their lives when possible. EVIDENCE: Service users spoken to confirmed that they are able to maintain their contact with their relative and friends and representatives. Service users had a choice of seeing these contacts in their own rooms or in the main lounge as they wished. During the day four relative were spoken to and confirmed that they visits are not restricted in any way and are always in private. Relatives were aware that they do sign the visitor’s book in accordance with the homes policy. Service users with more distant contacts confirmed that they always receive post and staff refer telephone calls via a mobile handset telephone for privacy. During the inspection children from a local school visited with service users, which the organiser confirmed occurs every Thursday during term time. Service users spoken to felt that they were able to exercise their personal choice and control where possible. They confirmed that staff are not intrusive into their financial affairs and always supported their personal preferences and choices. Service users also confirmed that they were encouraged to bring personal possession with them when they moved in. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Staff listen to and act upon service users and visitors views and complaints are resolved in line with the homes complaints policy. EVIDENCE: There is a clear and comprehensive complaints policy, which is also available in the service users guide. All service users spoken to during the inspection were aware of how to complain and were clear that they would speak to the nurse on duty should the need arise. Service users felt that their views would be listened to and acted upon. One service use discussed a minor complaint that she had raised with the staff and was satisfied with the outcome. All relatives spoken to where also clear on what to do should they need to complain if the need arose. Staff spoken to appeared to be clear of what to do in the event of a service user or visitor complaining and described a process of dealing promptly to resolve any issue. Staff were aware of the complaints book located in the main reception to record formal complaints. Two formal complaints were recorded since the last inspection and in both cases were resolved within the guidelines of the homes complaint policy. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26 Service users live in clean, pleasant and well-maintained environment. The walls in the laundry are not cleanable and care with storing items requiring disinfection are required to conform to best practise in controlling the spread of infection. The accessibility of the downstairs’ toilets should remain under review. EVIDENCE: The supernumerary nurse in charge gave a full and detailed tour of the building. Downstairs there is a large communal lounge and dining room that service users were using. The standard of cleanliness and décor of these areas were good and service users were satisfied with this area. Service users bedrooms were viewed and seen to be clean and comfortable and appropriately decorated. Many service users commented that they were very happy with their personal rooms. Toilets and bathrooms were also examined and found to be clean. It was noted that both downstairs toilets are narrow and cause problems with manoeuvring Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 15 of manual handling equipment at times as evidenced in the damage to walls. A review of this had been required in the previous inspection and the issue can only be addressed in one of the toilets when the adjacent room becomes available. The group manager remained aware of this issue. The building is not purpose built for access, however improvements have been made to include stair lifts and ramps and most areas of the home are now accessible. Service users could now access their bedrooms with staff assistance as required. Housekeeping arrangements in the home were satisfactory with a good standard of cleanliness throughout the home with the absence of offensive odours, except in one bedroom. This was addressed during the inspection. A member of the housekeeping team discussed their role and clearly understood good cross infection principles and COSSH procedures. The laundry has a separate room for clean and dirty laundry and both areas were tidy. The laundry assistant described an organised system for dealing with laundry and understood cross infection prevention. The laundry had two washing machines and dryers to meet the needs of service users laundry requirement. It was noted that the walls in the laundry were in a poor condition and were not readily cleanable and require redecoration. The sluice in the home is small and a backlog of items requiring cleaning was noted. There were a number of items waiting to be washed on the floor of the sluice room; this was not viewed as best practise. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Service users needs are met with a sufficient number and mix of nursing and care staff supported by an experienced ancillary team. EVIDENCE: Service users and relatives confirmed that they felt there are sufficient staff available on duty at all times. Service users confirmed that staff always answered call bells fairly promptly including during busy periods. During the morning of the inspection there were two RGN’s and five care assistants with an additional kitchen team, two housekeeping staff, a laundry assistant and a maintenance person. The rota demonstrated that this was the usual compliment of staff. Prior staffing levels were tracked for the previous four weeks and staffing levels were constant. The home does not use agency staff as confirmed by the group manager and senior staff on duty. The deputy matron is currently acting as the manager at present and during her days off in the week an additional supernumerary experienced nurse is on duty to provide cover. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 35 A manager must be recruited and registered for this service. Service users monies are safeguarded by the home policy and procedures. EVIDENCE: The previous manager has unfortunately recently left leaving the home without a manager again. There is currently an interim arrangement with the deputy acting up into this position. There has been a discussion with the group manager in regards to addressing this issue. A plan of action is required to address this situation. Service users confirmed that they are able to control their own monies. Service users monies are kept secure and separate from the homes. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 2 3 X 3 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X 3 X X X Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP4 Regulation 4 (3)(b) Requirement The registered person must ensure that service users are not admitted to the home with a diagnosis of dementia, as the home has not demonstrated its ability to meet this need and is not registered to provide this type of care. The registered person must ensure that the walls in the laundry are redecorated to ensure they can be cleaned to meet the specified minimum standard. The registered person provides a plan to ensure the backlog of contaminated equipment is not stored on the floor of the sluice room. The registered person provides a registered manager for this service. Action plan to be sent to the CSCI to address this issue by; Timescale for action 14/10/05 2 OP26 23(d) 31/12/05 3 OP26 13 (3) 30/11/05 4 OP31 8 30/11/05 Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 20 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 OP21 Good Practice Recommendations That the provision of adequate toilet facilities on the ground floor are reviewed when the adjacent bedroom becomes vacant. Sandridge House Nursing Home DS0000011014.V253459.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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