Inspection on 03/02/06 for Sandringham

This inspection was carried out on 3rd February 2006.

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

Sandringham 21/10/08

Sandringham 07/11/06

Sandringham 19/09/05

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 Valerie Buckle Unannounced Inspection 2.00pm 3 & 6 February 2006 rd th 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.V281477.R01.S.doc Version 5.1 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.V281477.R01.S.doc Version 5.1 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.V281477.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2005 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.V281477.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over four hours and 30 minutes. There was a tour of the premises, an inspection of a sample of records, policies and procedures. Two members of staff were spoken with and a number of residents were spoken to about their life at the home. The registered manager assisted with the process of the inspection, all the requirements and the good practice recommendations from the last inspection had been met. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 6 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.V281477.R01.S.doc Version 5.1 Page 7 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 Sandringham offers a good level of information to people thinking of using the homes’ service. Prospective residents are assessed prior to admission and have the opportunity to visit the home before making a choice about living there. EVIDENCE: The homes policies, procedures and information in the Statement of Purpose and Service Users Guide shows that a thorough pre-admission assessment takes place ensuring that the home can meet the needs and aspirations of the residents. Evidence that two residents visited the home for a trial period was seen and indicated that the residents visited the home to see the premises and meet the care staff and other residents before making a final decision about living there. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 8 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): 2, 9 The care planning process within the home is detailed and comprehensive and clearly identifies individual residents health, personal care and social care needs and wishes. Systems are in place in the home for the safer use, storage and recording or medicines. EVIDENCE: Care plans and risk assessments seen were detailed and comprehensive detailing individual residents needs. Risk assessments were documented for all areas of risk. Issues arising from the last inspection concerning a resident who had attempted to abscond had been addressed. The residents care plan had been amended and updated and included a risk assessment with strategies for staff on how to deal with absconding. There were clear guidelines for staff on managing the resident’s aggression and inappropriate behaviours. Daily care records were examined and were observed to be informative and detailed and included information relating to specific issues and detail which outlines the staffs interventions with residents. A medication policy and procedures are in place at the home. The medication administration records sampled were well maintained. Protocols were in place Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 9 for as and when required medication. Staff signatures and initials were evidenced in the Boots Monitoring System. A comprehensive introduction booklet for new staff was seen, this included a self assessment checklist for new staff. Staff have completed training on the safe use of medication, and further training is planned in this area. All medicines were seen to be stored appropriately and securely. None of the residents currently living at the home self administer their medication, locking cabinets are situated in residents rooms to use for medicines if the situation arises where a resident was admitted to the home who did self administer their drugs. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 10 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): 15 Residents receive a varied and appealing diet, which meets their requirements. EVIDENCE: A menu board displayed in the dining room showed the days choice of food available. Residents are able to choose from 2-3 main choices and alternatives to the menu are available. Food provided to the residents was attractively presented. Residents were seen eating lunch in a comfortable way. Staff were assisting residents who needed support, some residents were eating their lunch in their bedrooms, one lady was sitting in the conservatory enjoying her lunch. Residents commented that the food was good and there was a choice and that fresh fruit and vegetables are offered daily. An issue arising from the last inspection which concerned verbal interaction between staff and one resident at mealtime had been dealt with satisfactorily. It was noted that systems were in place to monitor that residents are treated with respect and dignity at all times. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 11 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): 17 Systems are in place at the home to protect resident’s legal rights. EVIDENCE: Residents who are able to use a postal vote. Resident’s finances were seen to be well documented and kept safe. Residents living at the home have their family, an advocate or solicitors to assist them with legal advice and support with their finances. During the course of the inspection it was evidenced that a recent incident which had occurred at the home which concerned a staff member rushing a resident at bath time was being investigated by the manager of the home. The issues raised had been dealt with and an action plan was put in place, which would monitor the situation and included the resident’s wishes concerning future bathing. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 12 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): 20, 21, 22, 23, 24, 25, 26 Residents live in a homely safe and well maintained environment, which meets their individual needs. EVIDENCE: On the days of the inspection the home was seen to be clean, tidy and odour free. It was comfortably furnished and decorated to a high standard. Resident’s rooms were seen to be personalised and individual with many personal belongings. A relatively new resident living at the home commented that she was very comfortable living at the home, very satisfied with her room which had ample space, she said the staff were very friendly and caring and that she had been encouraged to take her time in making a final decision about living in the home permanently, she said she had finally decided and that her family were now involved in helping her select items of furniture and personal belongings from her flat to make her bedroom feel more homely. Eight other residents spoken to all confirmed that they were happy living at the home and expressed that the staff were kind and caring. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 13 It was noted that an issue from the last inspection had been addressed. Systems were in place to ensure one resident who absconds is not able to leave the home without the care staff knowing, evidence was seen in the residents plan of care and risk assessment. There were sufficient bathrooms/toilets in the home and specialist equipment available to maximise resident’s independence. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 14 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): 29,30 Staffing levels at the home remain appropriate for the needs and numbers of residents. Sound staff recruitment practices were in place at the home. Training courses for staff remain a high priority. EVIDENCE: Four staff files examined were seen to contain all the required information as required by regulation and a five year work history. The manager of the home has just completed the NVQ 4 Registered Managers Award and at least 50 of the staff group are trained in NVQ. All staff have individual training profiles which include training courses completed and identified further training needs. All staff have completed mandatory training and regular updates take place. A sample of other courses completed by staff include POVA, Adult Abuse, Dementia, nutritional needs of the elderly, challenging behaviour and palliative care. The homes induction format was seen to be appropriate. Interactions between staff and residents was seen to be positive and staff demonstrated a good understanding and awareness of individual residents needs. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 15 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): 33, 34, 35, 36, 37, 38 The home is well managed by a qualified and experienced manager and is run in the best interests of the residents. Policies, procedures and records are in place, which protect residents. Staff supervision takes place regularly and staff within the home feel supported by the manager. EVIDENCE: Residents and staff spoken to expressed confidence in the way the home is managed. The registered manager is in day to day charge of the home and it is evident that the manager is competent and experienced to run the home and has a good understanding of the needs of the residents. Staff spoken to during the inspection said the manager is approachable and supportive. Minutes were seen of staff and residents meetings and there was evidence of regular staffs supervision and training taking place. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 16 A sample of policies, procedures and records were seen, which included health and safety of the home, a generic risk assessment, individual risk assessments for residents, residents files, records of medication and residents monies. Staff files and training profiles and the induction process for new staff. An annual quality monitoring system was in place, questionnaires about the quality of care provided were seen. Some had been completed by residents giving their views, families and professionals involved in the care of residents complete these questionnaires, a separate questionnaire for staff to complete was also seen. The Registered Manager said she would write a summary of the findings of these questionnaires and forward this to the CSCI once they have all been completed. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 3 3 3 Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 18 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 OP33 Good Practice Recommendations Good practice recommendation. The results of the service users survey should be made available to all interested practices including prospective residents and a copy sent to the CSCI. Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Sandringham DS0000015471.V281477.R01.S.doc Version 5.1 Page 20 - 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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