Inspection on 21/06/07 for Sandringham Road

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Road 08/07/09

Sandringham Road 04/03/06

Sandringham Road 12/11/05

Sandringham Road 03/03/05

Sandringham Road 22/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Sandringham Road 263 Sandringham Road Intake Doncaster DN2 5JG Lead Inspector Janet McBride Key Unannounced Inspection 21st June 2007 09:30 Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 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 Road DS0000007993.V330432.R01.S.doc Version 5.2 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 Adults 18-65. 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 Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandringham Road Address 263 Sandringham Road Intake Doncaster DN2 5JG 01302 739894 F/P01302 739894 NONE NONE South Yorkshire Housing Association 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) Post Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th March 2006 Brief Description of the Service: Sandringham Road provides residential care for six adults people of either gender with learning difficulties. Sandringham Road is a purpose built bungalow with the space, facilities and equipment to accommodate people with physical disabilities including wheelchair users. The accommodation is located at the edge of Intake/Wheatley Hills area of Doncaster. This suburb of Doncaster is about four miles from the town centre and there are local facilities such as shops, library and health centre close by. The home has an adapted minibus enabling access to the wider community. All people attend a range of day care provision that includes social education during Monday to Friday. Annual holidays, regular outings and social events are provided for everyone. The service is provided by a partnership between South Yorkshire Housing Association and Doncaster Healthcare Trust. South Yorkshire Housing Association own and operate the service with Doncaster healthcare Trust providing the staff. All people of the living at the home have a Licence agreement with South Yorkshire Housing Association. This partnership provides and operates three other such residential schemes in the Doncaster area. Information provided by the registered manager on the pre inspection questionnaire indicated that the current weekly fees for the home are £357:20 per week, as of June 2007. Additional charges are made for hairdressing, beautician, chiropody, toiletries/perfume and holidays/outings these costs are variable, for further information contact the home. The statement of purpose and the service user guide were available on request, which contained information about the services available at the home. The homes past published inspection reports were also available on request. A range of information that may be useful to people using the service or their relatives were displayed on the homes notice board. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this Key Unannounced Inspection, which took place on the 21st June 2007 for 6 hours. The home is registered for 6 people; at the time of inspection the home was fully occupied. Prior to the inspection the manager submitted a pre-inspection questionnaire giving information regarding the home and services provided. Analysis of this information and other relevant documentation for example, notifications and complaints were carried out before the inspection. Prior to the inspection comment cards were sent out to the home for them to distribute. Five were sent to people who use the service within the home, none were received back. Five were sent to staff members two were received back, and five were sent to professionals who had contact with the home and one was received back. They were asked to comment on the standard of care, staff skills, attitude, and how the needs of people using the service needs were met. All the comments made on the surveys are included in this report. During the inspection documentation and records were examined for example, medication, complaints, accident records, staff rotas, staff training files and case tracking of three care plans. These were cross-referenced with other relevant documentation relating to those people who use the service. Information was gathered from as many different individuals as possible, including individual interviews with members of staff. A tour of the premises and direct observation of staff interaction with people who use the service was carried out throughout the visit. The inspector would like to thank all the staff and people receiving services within the home for their co-operation in the inspection process on the day of the visit. No issues or concerns were raised on the day of the visit. Recruitment files were discussed with a member of staff at Doncaster Health Care Trust who confirmed that these staff files were held at the Trust site and were available for the Commission for Social Care Inspection to examine if required. What the service does well: Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 6 All the people receiving care within the home had been there since the home opened, they received a high standard of care, in comfortable surroundings and a relaxed atmosphere. People within the home had full needs assessments completed prior to moving into the home, and received on going assessments ensuring that any developing needs were met at all times. A very enthusiastic and stable staff group supported people within the home. Staff were observed to carry out their duties in a professional manner and showed consideration for peoples individual needs. Interaction between people using the service and staff was good humoured and kind. The three staff members on duty gave commendable support to people within the home who had high dependency needs. Daily routines and activities were recorded, for stimulation and enjoyment the home provided a range of activities both in and out of the home. People receiving the services had holidays arranged on a regular basis. All comments received on the day and from surveys were very positive about the home and the care delivered. 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. The summary of this inspection report can be made available in other formats on request. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &3. People who use the service experience Excellent outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People that use the service were individually assessed prior to admission to ensure their needs would be met. EVIDENCE: The home in conjunction with South Yorkshire Housing and the Doncaster Health Trust provided people who use the service or their relatives with information they need about the home and care available. Each person had on file a copy of a contract or Licence Agreement with SYHA. Records showed that introductory visits were offered and l people wanting to use the service would be invited to visit the home several times before being admitted on a permanent basis. Each of the three care plans examined had on going assessments ensuring that developing needs were met at all times. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9. People who use the service experience Excellent outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Care plans provided staff with sufficient information that ensured they could meet the care needs of people using the service; care plans were monitored and reviewed on a regular basis. EVIDENCE: People using the services at the home were highly dependent, some of who had complex needs. Three care plans were examined they contained a range of information, relevant medical details, and medication details. Most people living at Sandringham road had very complex needs and the detail in care plans reflected this. Involvement of other professionals was evident with assessments and ongoing in put from physiotherapist, consultant psychiatrist and speech therapist. Various risk assessments were in place that identified any risks or hazards dependent on individuals needs. Accidents were recorded and body maps were Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 10 used to identify bruises or injuries. Reviews and evaluation was done on a regular basis. All the care plans looked at were completed fully and included information about religious beliefs and how the individual should be supported in making choices and decisions. Whilst staff were supporting people within the home, during the morning it was clear that they understood individual’s needs. They supported people sensitively and helped people to make choices. This promoted the independence and life skills of each person. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17. People who use the service experience Good outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Regular opportunities were available for people to participate in a wide range of activities in the home, and in the wider community. Meals offered were healthy and nutritionally balanced. Likes and dislikes were catered for within the menus offered. EVIDENCE: For stimulation and enjoyment the home provided a range of activities both in and out of the home. The majority of people using the service went to day centres either once or three times a week. Shopping trips were planned, staff supported people to use local facilities e.g.shops, pubs and theatres whenever possible. Staff said that all people that use the service go on holiday once or twice a year. Three people within the home had been away early June to Blackpool for six days. Staff said that menus and mealtimes were planned to meet the needs of each individual at the home. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 12 A dietician was included in planning menus; this assisted in providing meals which met the specific needs of people who had swallowing difficulties. Care plans showed that people were nutritional assessed and weighed on a regular basis. Records were kept so that any changing needs could be identified and acted on. Records of activities were kept, these confirmed that a wide range of opportunities were available which reflected each persons interests. Regular support was provided by a variety of medical professionals to ensure the health of each person was promoted and maintained. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience Good outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People within the home had their health monitored and access to all NHS health care facilities. Staff ensured that all policies and practices were followed when medicines were administered. EVIDENCE: Care plans showed that people’s physical and emotional health care needs were met by the involvement of doctors, hospital, physiotherapists and occupational therapists along with the community nurses. Records clearly showed detailed information of personal care needs. Staff at the home said they promoted dignity, respect, wellbeing and independence for people within the home. Staff were seen to treat people with respect, kindness and dignity. Relatives are informed of advocacy services, and details were available on the notice board. Staff said advocacy services would be used for any person within the home if required. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 14 Medications were administered as prescribed by staff at the home, they said they worked to the homes medication policies and procedures. Observations and checking of medication records against stock confirmed all practices were satisfactory. This ensured that people living at the home were kept safe when receiving medication. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23. People who use the service experience Good outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People using the service and relatives were provided with information to enable them to raise concerns or complaints about the home and their care; staff had knowledge and understanding of adult protection issues, which promoted protection of service users from abuse. EVIDENCE: The South Yorkshire Housing Association and Doncaster Healthcare Trust had policies and procedures in place for complaints, concerns and to protect people from abuse. The home had a clear complaints system, which was produced in a user friendly format all complaints were recorded. Records checked showed no complaints had been received since the previous inspection. People using the service and relatives were provided with information to enable them to raise concerns or complaints about the home and their care. Advocates were available to provide an independent voice for people within the home. Records showed that all staff received training in adult protection and safeguarding issues during induction and foundation training and as part of National Vocational Qualification level 2 and 3 in care. Staff were aware of these polices and procedures, and could state the action they would take on receiving any allegations. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,29 &30. People who use the service experience Good outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People using the service live in a comfortable and accessible environment with specialist equipment provided to maximise their independence. EVIDENCE: The home is purpose a built bungalow which provides spacious accommodation for people using the service. The home was decorated and furnished to a very good standard, all areas were clean tidy, in good decorative condition and well maintained. Communal areas looked homely with comfortable armchairs, a sofa, dining table and dining chairs available. The home had a well equipped kitchen where staff members cook meals for people within the home. Bedrooms were individually decorated and furnished in a style that reflects that persons personality and interests. Personal belongings for example pictures, keepsakes, photographs and posters. Audio equipment, Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 17 televisions/VCRs, videotapes and CDs. Models and soft toys that bring pleasure and entertainment to those people within the home. Some people within the home had specialist beds with ceiling hoists to support their care needs. Other equipment they required to maximise their independence was made available as required. The home had a sufficient number of toilets and bathrooms for the needs of people using the service. The home was equipped with specialist adaptations to meet peoples needs, this promoted their independence. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36. People who use the service experience Good outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. The home had a very enthusiastic and stable staff group that worked positively with people to improve their quality of life within the home. Staff had undertaken basic and induction training which ensured that they were skilled and knowledgable. This ensured people at the home were supported and protected. EVIDENCE: Staffing levels were discussed with the person in charge of the day of the visit. Duty rotas examined showed appropriate staffing levels that supported people within the home in their day-to-day care needs. Three staff in the morning and afternoon with one waking staff member along with one sleeping in staff during the night time hours. The Doncaster Healthcare Trust has robust recruitment policies and procedures, staff recruitment records are held at the hospitals head offices. However discussions with both a member of staff at the Doncaster Healthcare Trust and new staff who were on duty, confirmed they had been interviewed, Criminal Records Bureau checks were completed, and two written references provided. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 19 There were job descriptions for all levels of staff, and a training strategy organised by the Doncaster Health Care Trust. This ensured that staff were skilled and knowledgable, which ensured people at the home were supported and protected. Staff training records showed that induction training for all new staff. Staff could also access Learning Disabilities Awards Framework (LDAF) and National Vocational Qualification level 2 in care (NVQ) training. The home had over 60 trained members of care staff with NVQ Level 2 and a number of staff had commenced on NVQ level 3. Records showed that staff had attended a range of training courses e.g. basic life support, food hygiene and managing violence and aggression training. Staff confirmed they had an individual training file, and training opportunities were offered, they also confirmed that they received regular supervision sessions. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42. People who use the service experience Excellent outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People who use the service were protected and safeguarded by sound management practises. Policies, procedures and training practices ensured that people were safeguarded and protected. EVIDENCE: There were policies and procedures, which promoted the health, safety and welfare of people within the home. Staff and the providers undertook all necessary health and safety checks, which promoted the health and well being of people who use the service. Health and safety was discussed with the staff on duty and various records were examined. The home was maintained, checks were undertaken for example fire prevention, all records were up to date and satisfactory. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 21 Staff received regular health and safety related training, e.g.moving and handling, food hygiene, first aid course and basic life support training. Accident records were correctly kept so that any trends and patterns could be identified and dealt with. The Trust and the SYHA undertake audits for the routine checks and services are carried out on the building, equipment and appliances. The Commission for Social Care Inspection received regulation 26 reports on the monthly monitoring visits and annual business report from South Yorkshire Housing Associating. One issue raised by staff was the lack of being able to access the internet to gain information, no e-mails address for the home to send and receive e-mails, which does raise concerns. The pre inspection questionnaire had to be completed by hand. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 4 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 4 X Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 23 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 YA37 Good Practice Recommendations The registered provider should consider installing a system that ensures the manager can access the internet to gain information, send and receives e-mails. This would also encourage research and development of the service. Sandringham Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Road DS0000007993.V330432.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!