Inspection on 15/03/06 for Sandringham House

This inspection was carried out on 15th March 2006.

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 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 House 25/10/08

Sandringham House 29/10/07

Sandringham House 02/06/06

Sandringham House 10/10/05

Sandringham House 03/02/05

Sandringham House 07/10/04

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

CARE HOMES FOR OLDER PEOPLE Sandringham House 26 Sandringham Road Lower Parkstone Poole Dorset BH14 8TH Lead Inspector Hilary Cobban Unannounced Inspection 15th March 2006 10:00 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 DS0000020491.V286740.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. DS0000020491.V286740.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sandringham House Address 26 Sandringham Road Lower Parkstone Poole Dorset BH14 8TH 01202 744409 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) Miss E Smith Mrs Doreen MacLennan Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places DS0000020491.V286740.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit two persons, as known to the NCSC, under the category DE (under 65) 10th October 2005 Date of last inspection Brief Description of the Service: Sandringham House is situated in a residential area of Lower Parkstone, a short walk from the local shops and within easy reach by car or public transport of Parkstone, Poole and Bournemouth. A passenger lift and stairs provide access to the resident’s bedrooms, which are on both floors of the home. A half landing between floors is accessible only by the stairs and a single bedroom and assisted bath are situated on this level. The communal areas of a lounge/dining area and kitchen are located on the ground floor. The home provides adequate toilet and bathroom facilities as well as sluicing area on both floors. The laundry room is sited in the garden to the rear of the home and also serves as a staff room. The home provides some off road parking at the front of the home. DS0000020491.V286740.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection, which took a total of six hours, was carried out over two consecutive days, thus enabling the inspector to meet the Registered Provider, Miss Smith, and the Registered Manager, Mrs Maclennan. The inspector took the opportunity to talk with two qualified members of staff and two care assistants as well as one visitor, and also to sit with the service users and observe their care. There were no service users within the category of under 65. The inspector was looking at three requirements from the previous inspection, two of which have been addressed and examining the remaining core standards and a variety of other standards, including environmental issues and health and safety. What the service does well: What has improved since the last inspection? Miss Smith informed the inspector that various items of kitchen equipment had been purchased since the last inspection, together with two wheelchairs and various pressure relieving mattresses and cushions. Three bedrooms had been redecorated and carpeted. A fax machine had been purchased and some new guttering installed. The Recruitment records are now in line with the requirements of Schedule 4 of the Care Homes Regulations 2001 DS0000020491.V286740.R01.S.doc Version 5.1 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. DS0000020491.V286740.R01.S.doc Version 5.1 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 DS0000020491.V286740.R01.S.doc Version 5.1 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): 3&6 The Pre-admission assessment procedures are limited which means it is unclear whether the home can meet the individuals needs or not. The home does not offer intermediate care. EVIDENCE: The Inspector examined preadmission assessments for three service users, including the most recent admission and found these to be inadequate. The Registered Provider, who is not a qualified nurse, is still carrying these out with advice from a trained person on the ward, who is named on the form. She then discusses the assessment with her Care Manager who makes the final decision as to whether the home can meet the needs of the service user. The Inspector spoke to the husband of a recent admission and he said he had not been involved at any stage. This pre-admission assessment should be referred to when making the initial plan of care. This was not obvious from the care plan. DS0000020491.V286740.R01.S.doc Version 5.1 Page 9 This has been a requirement from the previous three inspections and could result in enforcement action unless there is a marked improvement. The home does not offer intermediate care DS0000020491.V286740.R01.S.doc Version 5.1 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 & 10 The individual care plans and risk assessments were inadequate thus jeopardising the health and personal needs of the service users. The layout of the building deems it difficult to maintain privacy and dignity when using the assisted toilet and bathroom but the care staff do use screens. EVIDENCE: The Inspector examined the care plans of four service users and found that none had current risk assessments for moving and handling, tissue viability, nutritional assessment or for the appropriate use of bed rails. Neither the risk assessments nor daily care evaluations referred to the needs of the service user. The continence assessments were basic and carried out by a care assistant, who did not always take advantage of a recognised assessment tool. There was one falls risk assessment, which had been signed by a relative. The wound charts were also inconsistent with the daily care evaluations. The reviews were carried out at irregular intervals with no recorded reference to the service user or their representative. DS0000020491.V286740.R01.S.doc Version 5.1 Page 11 The service users are weighed monthly but no action is taken because of any weight change. The Inspector sat with the service users and noted that the staff appeared to give appropriate care but records must be kept of this. The Registered Manager must seek advice on ways of improving the care plans to meet this standard. The staff were seen to address the service users with the name of their choice and treated them with respect. Locks are not fitted to the doors and a record is kept that this is not appropriate for these particular individuals. DS0000020491.V286740.R01.S.doc Version 5.1 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): 12, 13 & 14 The staff give choice and flexibility to the service users within the limitations of the service user group. Service users maintain contact with friends and family but there is little contact with the local community. It was difficult to ascertain the extent of the leisure and social activities as no records are kept of this. EVIDENCE: The Registered Manager and care staff informed the Inspector that there is an Extend Therapy Class every week. There should be records of who attends this and other entertainment. Most of the service users were sitting in the lounge area but it was noted that those who were able could go back to their own rooms when they wished. The Registered Provider stated that the home does not look after any personal funds for the service users. The Registered Provider stated that there was a choice of meals but on the day of the inspection all the service users were having the same meal, which was ample and nutritious. Few service users were able to come to the table. DS0000020491.V286740.R01.S.doc Version 5.1 Page 13 A relative spoken to stated that he was always made to feel most welcome at any time. He had been given a lot of information about the home. He confirmed that service users wear their own clothes and the Registered Manager stated that choice of outfit is given where possible. The service users looked as though attention was paid to their personal appearance. None of the service users are able to handle their own financial affairs. A solicitor is used for those without a personal representative. DS0000020491.V286740.R01.S.doc Version 5.1 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 the following standard(s): No standards were inspected EVIDENCE: DS0000020491.V286740.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21,22,24,25 & 26 The home is not well maintained and many areas of the premises are in need of decoration The home has not yet installed all the specialist equipment which is necessary to maximise the independence of the service user. The hot water system must be adequately controlled to ensure the service users live in safe surroundings. The home was not clean on the day of the inspection but was free from odour. The laundry facilities are unsavoury which compromises the hygiene within the home DS0000020491.V286740.R01.S.doc Version 5.1 Page 16 EVIDENCE: Some of the furnishings around the home were in a poor condition and might be hazardous to health. Some areas of the home are still in need of decoration, particularly the outside. The lighting in the bedrooms was not all of a domestic nature-see immediate requirement. The previous inspection noted that a grab rail must be fitted to a bathroom as per the requirements of the Occupational Therapist. This has still not been done. The home complies with the requirements of the local Fire Service and environmental health department. However, the inspector observed that the home was cluttered due to limited storage facilities. Access to the bathroom and toilets is restricted by the lay out of the home and waste bins in the bathrooms and toilets were overfull and uncovered. There was also found to be a communal pot of skin cream in use and one named cream was in use for the wrong service user. The communal area is limited but is within the legal requirement. It was noted that corridors are lit using strip lighting. The temperature of the water from the taps was found to be in excess of 70 degrees Celsius. An immediate requirement was made for this to be rectified. The staff must keep a record of water temperature testing. The Registered Provider has been asked to provide evidence that tests have been carried out to prevent the risks from Legionella and Water Supply (Water Fittings) Regulations 1999. The laundry is situated in a wooden shed detached from the main building. The Inspector was concerned that laundry is carried through the dining room and recommended that the floor and walls be washable to prevent the risk of infection, as the wooden floor was stained and damp on the day of the inspection. There are two sluices, which also are an infection risk, due to their access and lack of cleanliness. DS0000020491.V286740.R01.S.doc Version 5.1 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 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): 28 & 29 The care staff appeared competent which ensured that the service users are in safe hands at all times. The recruitment records of the only new member of staff were in order which ensured the protection of the service users. EVIDENCE: Three members of staff have already achieved their National Vocational Qualification in Care Level 2 and a further two are hoping to register shortly. The inspector spoke to two care assistants, both of whom have benefited from the units achieved within their recognised training. The home has a very stable staff complement and offers various mandatory training to all throughout the year. The records of a recently recruited member of staff were examined and found to be in order, with two references (one both verbal and written) and a police check with the Criminal Records Bureau was successfully returned before she commenced work to ensure the protection of the service user. It was suggested that any gaps in employment history be recorded. DS0000020491.V286740.R01.S.doc Version 5.1 Page 18 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): 32, 33, 37 & 38 The Registered Provider now has a more formal management approach. There is no structured quality assurance system in place. This is necessary so that the home is run in the best interests of the service user. The record keeping is inadequate, as mentioned elsewhere in this report and the policies need to be reviewed regularly. This evidence is required to ensure the best interests of the service user. There are shortcomings in the health and safety measures, which must be addressed to protect the service users. DS0000020491.V286740.R01.S.doc Version 5.1 Page 19 EVIDENCE: The Registered Provider stated that she is in the home at least three times a week and has extensive knowledge of the organisation. She now has a formal meeting with the Manager, which is recorded and refers to various areas such as staffing, occupancy, the fabric of the home and any unusual occurrences. The inspector asked that copies of this be sent to the Commission for Social Care Inspection to comply with Regulation 26. The Registered Manager feels that she has adequate support. There is no Quality Assurance Scheme in place and it was pointed out that a through audit might have alerted the Registered Provider to the shortcomings of the home. The Policies and Procedures are inaccessible and have not been reviewed on a regular basis. There are gaps in the record keeping as mentioned elsewhere in this report, and the records are not all kept secure in line the Data Protection Act 1998. The Inspector identified several areas where the Health Safety and Welfare of service users was at risk, such as the unlocked cupboard for storing cleaning fluids including hazardous substances, the hot water and an exposed strip light. The radiators are all covered but there are still mobile heating appliances in use. The upstairs windows are all restricted and there is external heat sensitive lighting. The front door is locked at all times and chains have been fitted to the side door. Risk assessments have not been carried out for safe working practices- such as the use of bed rails (see Standard 7) Accidents are recorded in a suitable book but must be filed according to the Data Protection Act. Accidents should be audited and appropriate action taken. Fire equipment is checked and Training given to staff according to guidance from the Dorset Fire Rescue Service but it was recommended that the training is more specific. The Inspector recommended that a fire safety device be installed in the laundry room. The other mandatory training is given to the staff but should be charted in a manner where gaps can be easily recognised. DS0000020491.V286740.R01.S.doc Version 5.1 Page 20 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 X 1 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 3 3 2 X 3 1 1 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 1 X X X 1 1 DS0000020491.V286740.R01.S.doc Version 5.1 Page 21 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 OP3 Regulation 14 Requirement Service uses must only be admitted to the home based on a full assessment undertaken by people trained to do so. This is a repeated requirement from the inspections on 7-10-04 and 3-2-05 and 19-10-05. The Care Plan must be written in sufficient detail to ensure that the needs of the service user are met. Risk assessments must be carried out on aspects of daily living. The home must be maintained in a good state of repair. Lighting must be suitable and safe for service users. The water temperature must be regulated so that it leaves the taps at no higher than 43o Celsius. The home must be clean and hygienic. All waste bins must be emptied regularly and have fitted lids to prevent the risk of infection. Timescale for action 01/06/06 2. OP7 15 (1)(a) 01/06/06 3. 4. 5. 6. OP8 OP19 OP25 OP25 13 (4) (b) 23 (2) 13(4) 13 (4)(a) 01/06/06 01/08/06 15/03/06 15/03/06 7. 8. OP26 OP26 13(3) 13(3) 01/06/06 01/06/06 DS0000020491.V286740.R01.S.doc Version 5.1 Page 22 9. 10. 11. OP33 OP33 OP37 24(1)(a) 12(1)(b) 17(1)(a) 12. 13. OP38 OP38 13(4)(a) 13(4)b) The Registered Provider must introduce a thorough quality assurance system The policies and Procedures must be accessible to staff and updated regularly The Registered Provider must maintain all the records as specified in Schedule 3 of the Care Homes Regulations All substances hazardous to health must be locked away safely Risk assessments must be carried out on the appropriate use of bedrails 01/06/06 01/06/06 01/06/06 15/03/06 01/06/06 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. 3. 4. 5. Refer to Standard OP12 OP22 OP26 OP25 OP26 Good Practice Recommendations The Registered Manager should keep a record of activities, which includes which service users are involved. The Registered Provider should install a grab rail in the bathroom as suggested by the Occupational Therapist The laundry floor and walls should be readily washable to prevent the spread of infection The Registered Provider should ensure that the water is distributed at the correct temperature to prevent risks from Legionella. The Registered Provider should supply evidence to the Commission for Social Care Inspection that the water supply complies with the Water Supply (Water Fittings) Regulations 1999 Any gaps in employment history should be identified The Reporting of Accidents should comply with the Data Protection Act 1998 The Fire Training should specify the topics addressed. 6. 7. 8. OP29 OP38 OP38 DS0000020491.V286740.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000020491.V286740.R01.S.doc Version 5.1 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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