Inspection on 19/09/05 for Sandringham

This inspection was carried out on 19th September 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

Sandringham 21/10/08

Sandringham 07/11/06

Sandringham 03/02/06

Sandringham 07/12/04

Sandringham 03/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Sandringham 5-7 Westcliff Avenue Westcliff On Sea Essex SS0 7QR Lead Inspector Michelle Love Unannounced Inspection 19th September 2005 08:30 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 Sandringham DS0000015471.V251134.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. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sandringham Address 5-7 Westcliff Avenue Westcliff On Sea Essex SS0 7QR 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) 01702 352911 01702 430650 Darby and Joan Organisation Mrs Anna Searle Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2004 Brief Description of the Service: Sandringham provides accommodation for up to twenty older people. In addition the home is registered to take those people who have a formal diagnosis of dementia. The home is situated close to the towns of Southend, Westcliff and Leigh and a short distance from the seafront. The homes facilities include a lounge, dining area, conservatory/quiet area and twenty single bedrooms with en-suite facilities. The home has a passenger lift, which provides access to all floors. The home offers a small rear garden and there is limited off street parking to the front of the premises. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors, Michelle Love and Sarah Axam. The inspection lasted a total of eight hours. A number of records and documents were inspected and a tour of the premises was undertaken. During the inspection the registered manager, care staff, visitors and relatives were spoken with. What the service does well: What has improved since the last inspection? The care planning processes within the home, were much improved and this is reflected within those care plans/risk assessments and other documentation inspected. Commitment continues in relation to providing all members of staff with appropriate training. Training records for staff were well managed and organised. Since the last inspection the number of double shifts/excess hours previously worked by some members of staff have reduced significantly. Sandringham DS0000015471.V251134.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. Sandringham DS0000015471.V251134.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 Sandringham DS0000015471.V251134.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): 2, 3, 4 and 5 Prospective residents are assessed prior to admission and have the opportunity to visit the care home so as to make an informed choice as to whether or not Sandringham is a care home they wish to live in. All residents are provided with a Statement of Terms and Conditions. EVIDENCE: Pre Admission Assessments were completed for the newest residents to be admitted to the care home. In addition formal dependency profiles were completed detailing those residents who fall into the specific High, Medium and Low categories. Evidence that one resident visited the home prior to admittance for a trial visit was available and indicated that they visited the home so as to see the premises and to meet care staff and other residents. A Statement of Terms and Conditions was available for residents and both were signed and dated. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 9 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, 10 and 11 The care planning process within the home are detailed and comprehensive and clearly identifies individual residents health, personal and social care needs. The care plans provide a good basis for care to be delivered to residents. EVIDENCE: On inspection of five individual care plans and risk assessments, these were seen to be detailed, informative and comprehensive detailing individual residents needs pertaining to health, personal, social and physical care needs. Evidence was available to indicate that the care plan is reviewed monthly and care plans reflect changes in need. Formal assessments were evident in relation to pressures sores and manual handling. Risk assessments were documented for nearly all areas of assessed risk. One residents care plan/risk assessment did not detail that they had attempted to abscond from the care home. Clear written guidelines must be available for all staff in relation to how to deal with individual resident’s aggression/inappropriate behaviours. This was not available for one resident. Daily care records were written on a daily basis and in general terms were observed to be informative and detailed. Some Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 10 entries require additional information in relation to specific detail outlining staff interventions. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 11 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): 12, 13, 14 and 15 Opportunities are available on a regular basis for residents to participate within an activity programme. Residents are enabled to access the local community wherever possible. Residents receive a varied and appealing diet, which meets their requirements and needs. EVIDENCE: The home does not employ an activities co-ordinator as the expectation is that all care staff employed at the care home will initiate and participate within the activity programme. There is a weekly programme of activities for residents ranging from board games, sing a long, massage, newspapers and external independent entertainers. Throughout the year residents are supported to access local facilities i.e. Cliff’s Pavilion, Palace Theatre etc. A montage of photographs evidencing activities undertaken by residents, were available within the care home. Care Plans evidenced resident’s personal preferences, likes and dislikes pertaining to leisure pursuits and interests. A menu board in the dining room depicted the day’s choice of food available. Residents are able to choose from 2-3 main choices on offer and alternatives to the menu are available. The inspectors were advised that 1x resident requires physical assistance by care staff for feeding and 2x residents require minimal physical support/verbal prompting. Specialist cutlery is available for Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 12 one resident. Food provided to residents was attractively presented and plentiful. In general terms the lunchtime meal was unhurried for residents and interaction between some care staff and residents was observed to be good. However two members of care staff lacked skill in their verbal interaction with residents and also one member of care staff was seen to act rather impatiently whilst feeding one resident. These observations were relayed to the registered manager at the time of the inspection. Sandringham DS0000015471.V251134.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 and 18 The home has a clear complaints procedure and adult protection policy and procedure available. It was evident that the registered manager and some care staff have knowledge and understanding of adult protection issues, which protects residents from abuse. EVIDENCE: Since the last inspection the home has received one complaint. Records were available detailing how the complaint was dealt with/addressed. A number of compliments were also evidenced. Both the registered manager and two members of staff were able to demonstrate a general awareness of Protection of Vulnerable Adults procedures. Further training for some staff is planned pertaining to Protection of Vulnerable Adults for the 2005-2006 period. Sandringham DS0000015471.V251134.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 Residents live within a homely, safe and well maintained environment. EVIDENCE: On the day of inspection the home was observed to be clean, tidy and odour free. Resident’s bedrooms were seen to be personalised and individualised with many personal affects on display. Of those residents spoken with all confirmed that they were happy with their own private space. No health and safety issues were highlighted at the time of the inspection. A chair was observed to be placed in front of the open main entrance to the home. When questioned a member of care staff and the registered manager advised that the decision to place a chair by the open entrance was as way of a deterrent to stop one resident leaving the care home without care staff knowing. The registered manager was advised that this is unacceptable and an alternative solution must be sought. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 15 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, 28, 29 and 30 Staffing levels at the home remain appropriate for the needs and numbers of residents. Some gaps exist in relation to those records required pertaining to staff recruitment. Training courses for staff remains a high priority. EVIDENCE: Staff rosters showed that agreed staffing levels are being maintained and that previous concerns relating to care staff working long days/double shifts have reduced significantly and only occur occasionally. The manager’s hours remain supernumerary to the staff roster. Currently there are no staff vacancies and the home does not use an external agency to cover staffing shortfalls. On inspection of five staff recruitment files some gaps were observed in relation to those records required by regulation i.e. some employment histories were not fully explored and no evidence of qualifications and experience for some members of staff. Since the last inspection some staff have received/undertaken training relating to Manual Handling, Falls Management, Managing Incontinence, Health and Safety, Dementia Awareness, Basic First Aid, Infection Control, Protection of Vulnerable Adults, Safe Handling of Medicines, Nutritional Needs of the Elderly, Appraisal Training, Fire Training, Dealing with Challenging Behaviour, Pressure Area Care, Pallative Care and Basic Food Hygiene. Three members of staff have completed NVQ Level 2, 1x member of staff is currently undertaking NVQ Level 2 and 4x members of care staff are to enrol on the NVQ programme. The homes induction format for newly appointed members of staff was seen to be appropriate. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 16 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 32 The home is managed well and staff within the home feel supported by the registered manager. EVIDENCE: The registered manager is in day to day charge of the home. It is evident that the manager is competent and experienced to run the home and has a good understanding of the needs of current residents. Staff spoken with during the inspection stated that they felt the manager was approachable. The registered manager has completed the `care component` of the registered managers award so far. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 17 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X X Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 18 YES 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 OP7 Regulation 13(4)(c) Requirement The registered person must ensure that unnecessary risks to residents are identified and wherever possible eliminated. Risk assessments must be devised for all areas of identified risk. (Previous timescale of 01.04.05 not met) Timescale for action 01/01/06 2 OP15 12(4)(a) 3 OP29 17(2), 19 Ensure that suitable 14/11/05 arrangements are made for staff to work in a way that shows respect for residents and their dignity. The registered person must 01/12/05 evidence robust and safe recruitment procedures and have all the required records and documents. (Previous timescale of 01.02.05 not met) Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 19 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 2 Refer to Standard OP7 OP28 Good Practice Recommendations Daily care notes should also include details of staff’s interventions. 50 of care staff should achieve NVQ Level 2. Sandringham DS0000015471.V251134.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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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