CARE HOMES FOR OLDER PEOPLE
Sandringham Care Home with Nursing Escomb Road Bishop Auckland County Durham DL14 6HT Lead Inspector
Belinda Parker Unannounced 9:00am 10 August 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. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sandringham Care Home with Nursing Address Escomb Road Bishop Auckland County Durham DL14 6HT 01388 660930 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) Ladhar Group Homes Joan Purcell CRH with nursing 90 Category(ies) of DE(E) Dementia over the age of 65 years registration, with number OP Old age, not falling within any other category of places DE Dementia Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The home may accommodate a named individual as set out in the letters to the registered person dated 14 June 2005 & 29 July 2005 which establishes the basis on which the individual`s needs will be met by the home. Where necessary the homes statement of purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individual who falls outside the registered category. Date of last inspection NA Brief Description of the Service: Sandringham Care home is a care home with Nursing including Dementia opened in May 2005 and provides accommodation for 90 older persons . The building is purpose built and provides accommodation on three floors. The home is located near to the general hospital and town centre. All service areas are located on the ground floor. The home provides safe accessible outdoor areas with seating for service users to enjoy. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first Inspection for Sandringham Care Home and took place over a period of 7.5 hours. During the inspection time was spent talking to service users, the manager, staff and relatives. The inspector toured the home and a number of records were examined. What the service does well: What has improved since the last inspection?
This is the first inspection for this recently opened home. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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) 3,4 and 5 The process for admission to the home is clear. Pre-admission assessment procedures involve service users and their relatives to enable them to make an informed decision as to whether they service user wishes to come and live in the home. EVIDENCE: The manager said she visits all new service user admissions and re-admissions and carries out an assessment to ensure the home has the capacity to meet the individual needs of the service user. The manager said the prospective service user’s relatives are involved in the process. The manager said the majority of admissions tend to be from hospital. Relatives and the service user’s social worker are invited to visit the home prior to admission of the service user. Relatives of a service user who had recently been admitted to the home said they had been involved in the assessment process. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 and 11 There was a clear care planning system in place that adequately provided staff with the information required to satisfactorily met the needs of the service users. The procedure for documenting medication was incomplete and may put service users at risk. EVIDENCE: Six care plans examined contained all the information required to enable staff to meet the needs of the service users. Care plan documentation was up to date. Care plans contained a record of visits and involvement from other health care professionals for individual service users. All service users are registered with a GP in the area. Evidence was available to show that the manager is currently completing an audit of all care plans. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 10 The procedure for recording hand written entries on the medication recording sheet did not always show an accountability signature of the person responsible for receiving the medication into the home. Due to this procedure not being followed properly service users may be put at risk. Not The home had in place a policy on death and dying, which included information on other cultures and religions. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 standard(s) 12 and 15 The choice of activities is limited at present and does not offer a suitable range of activities to meet the collective needs of service users. Dietary needs of service users are well catered for with a balanced and varied selection of food that meets service users needs and choices. EVIDENCE: The manager said the home has appointed an activities co-ordinator who will shortly commence employment. Staff said they are currently providing a range of activities for service users in the home but due to work load are limited. Service users said the routine in the home was flexible. One service user said she likes to maintain a beauty routine and commented, “ I like to look like somebody, not nobody”. A meal sampled in the home was hot and tasty. A choice of meals were available, offering service users choice. A daily record of meals eaten by service users was maintained to ensure service users were eating a balanced diet. Service users commented that the food was good. It was observed during the inspection the chef chatting to service users. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 12 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 and 18 The complaints process in this home needs to be made clear to relatives of service users, to enable them to comment when they feel the service is not satisfactory. Knowledge of POVA by staff working in this home is limited, which may put service users at risk. EVIDENCE: The home has in place a clear complaints procedure that sets out the process, timescale and outcome. There have been no recorded complaints since the home opened in May 2005. The manager said she needs to make clear the complaints process to relatives of service users, to enable them to comment if they are unsatisfied with any area of the service. POVA (Protection of Vulnerable Adults training) needs to be arranged for all staff, ensuring staff are aware of the process if an incident of abuse occurs in the home and for the protection of service users. One of two staff interviewed was able to demonstrate a knowledge of POVA. All staff files checked contained a current Criminal Records Bureau check for the protection of service users. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 13 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) 19,20,21,22,23,24,25 and 26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: On touring the home it was observed to be clean, comfortable, accessible and safe for service users. Service users were observed to be moving around the home freely. Relatives and service users spoken to during the inspection commented favourable on the high standard of décor, furnishings and comfort. Communal areas and personal accommodation was spacious, light and airy. One service users showed me her family photographs and personal possessions that she had been able to bring into the home on admission. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 14 Care plans contained evidence to show that an assessment of service users specialist disability needs had been carried out. The home had in place a range of disability equipment to meet the collective needs and individual needs of service users. The home was light, bright , airy, well ventilated and odour free. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 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 and 29 Staffing levels in the home satisfactorily meet the collective needs of the service users who live there. Recruitment procedures for staff are thorough ensuring the protection of service users. EVIDENCE: Staff were employed in adequate numbers and skill mix to meet the collected needs of the service users. The manager said service user numbers are gradually increasing. The manager continues to recruit to ensure competent and skilled staff are available to meet the needs of the increasing number of service users living in the home. The majority of care staff employed have a minimum of NVQ2 in Care, arrangements are being put in place for other care staff to achieve this award to enable them to acquire the skills and abilities to meet service users needs. Staff personnel files examined contained evidence to show that a thorough process of recruitment had been followed to ensure the protection of service users living in the home. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 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) EVIDENCE: This standard section was not assessed at this inspection. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x x Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 18 NA 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 9 Regulation 13 (2) Requirement Timescale for action 24 hours 2. 12 16 (m, n) 3. 16 22 4. 18 18 (c-i) The registered manager shall make arrangements to ensure all hand written entries on the MAR sheets are signed for by the person responsible for the receipt of medication into the home. The registered manager shall 30/9/05 consult service users about their social interests and arrange a programme of activities meeting the collective needs and choices of the service users living in the home. The registered manager shall 30/9/05 supply a copy of the complaints procedure to any person acting on behalf of the service user for information. The registered person shall make 1/11/05 arrangements for staff to attend POVA training for the protection of service users living in the home. Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 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. Refer to Standard Good Practice Recommendations Sandringham Care Home with Nursing B54 S63946 Sandringham Care Home V243131 100805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Dar;lington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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