Inspection on 10/06/05 for Sandrock House

This inspection was carried out on 10th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sandrock House 11/06/07

Sandrock House 12/12/05

Sandrock House 20/12/04

Sandrock House 25/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE SANDROCK HOUSE 53 Bawtry Road Bessacarr Doncaster DN4 7AA Lead Inspector Sarah Powell Unannounced 10 June 2005 13:15 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. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sandrock House Address Sandrock House 53 Bawtry Road, Bessacarr, Doncaster, South Yorkshire, DN4 7AA 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) 01302 535634 01302 535634 n/a Sherwood Care Homes Limited Joyce Richardson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Sandrock House is a care home providing accommodation and personal care for 20 service users in a converted building with an extension at the rear. All the bedrooms are single with en-suite toilet facilities except one. There are two floors the upper floor is accessed by a stair lift. Nursing care is not provided. A small independent company owns the home with one of the owners being on site frequently overseeing the business. The home is in Bessacarr, Doncaster and has amenities nearby. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection in the year 2005/2006 and took place over one day the inspection commenced at 13.15 and finished at 17.45. The previous requirements were looked at with the manager. 13 Service users 4 visitors and 3 staff were spoken to. A tour of the building took place, observing staff and practices including activities and meals. 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. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 & 5 Service users are given information to make a choice and all service users are assessed and only move into the home if their needs can be met. EVIDENCE: The service users guide and statement of purpose were available in the home and all service users have a copy of the service user guide, these both contained all the relevant information required. Informing the service users of the services available to them in the home ensuring them their needs will be met. All prospective service users have a full assessment carried out by the home manager these were seen in the plans of care they were comprehensive and evidenced that the home was able to meet the needs of the service users that move into Sandrock. All prospective service users and their families are invited to look round the home, spend the day, stay for a meal or stay the night to ensure that there needs can be met and that they are happy with the home. The service users and relatives that were spoken to confirmed this. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 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 standard(s) 7 & 11 All service users care needs were set out in individual plans of care including dealing with increasing needs and death. EVIDENCE: The plans of care looked at were very good all assessments completed and problems identified, although there was some duplication. Risk assessments were completed for the service users ensuring staff were aware of the needs and risks for all service users and were able to care for them appropriately. Staff confirmed that they gave care and comfort to service users who are dying and treat them with respect and dignity. The service users wishes concerning terminal care and arrangements after death are not always discussed this needs to be addressed and the service users wishes documented so that at the time of death their wishes are followed through. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 9 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) 15 Service users receive an appealing balanced diet. EVIDENCE: The home provided an appealing balanced diet the service users spoken to all commented that the food was very good always had a choice and was well presented. The inspector observed the evening meal being served during the inspection. The service users who had this meal in their rooms were given their meal at 4pm, which is rather early; the meals are then served in the dining room at approximately 4.45pm. This gives a long gap between the evening meal and breakfast the following morning at 8am, service users told the inspector that supper was not offered, they could ask for something to eat but it was not offered. Suppers must be offered so as there is not a large gap between meals. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 10 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 & 18 Service users are protected from abuse and there is a clear and accessible complaints procedure. EVIDENCE: The Manager has provided a very simple easy to follow complaints procedure, which meets all the requirements of the standard and is accessible to all service users, relatives, visitors and staff. Service users told the inspector if they wished to make a complaint they would approach the manger as she always listened and took all concerns seriously and acted on them. The protection of vulnerable adults policy was excellent providing an easy to follow step-by-step guide with all relevant contact numbers included. All staff were aware of adult protection and had received the necessary training to safeguard the service users. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 11 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) 21 & 26 The standard of cleanliness in the home was excellent. There were sufficient toilets for service users however; the bathing facilities did not meet the needs of the service users as their needs are increasing. EVIDENCE: During the tour of the building it was seen that only one of the bathrooms was being used, this was the assisted bath, the manager explained that due to the increasing needs of the service users the other baths were not suitable, however this only provided one bath for 20 service users. The green bathroom has a very small bath, which could easily be changed to a walk–in–shower, which would benefit the service users. Comments received from service users included “there was no shower in the home and it would be nice to have a shower”. The standard of cleanliness observed during the tour of the home was excellent and all service users and visitors spoken to all commented that the home was very clean. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 12 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 & 30 Staff training must be improved to ensure needs of service users are met at all times. EVIDENCE: The mandatory training for staff was not up to date this needs to be addressed so that service users are in safe hands at all times. The manager was aware this needed addressing and intends to prioritise this to ensure service users needs are met. The staff complement needs more senior staff, at present there is the Manager and one senior carer this leaves some shifts in the evenings and weekends without a senior on shift and lack of leadership which could put service users at risk. NVQ training is very good with 9 staff just completing NVQ level 2 this will be over 50 of care staff, which will make them better qualified to meet the needs of the service users. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 13 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) 31 & 36 The manager is competent and experienced to run the home. Supervision records are not up to date. EVIDENCE: Since the last inspection the manager has been registered with CSCI as the Registered Manage having successfully completed the fit person interview. The manager has completed 6 units of the Registered Managers Award and hopes to complete by November this year. This enables service users to live in a home, which is well run and managed. Supervision records were not up to date some night staff and weekend staff have not had supervision for over 2 years. The manager and senior carer are the only two members of staff able to carry out supervision so this is why some staff that they do not work with are getting missed. If there were more senior care staff this would not happen. It was also not clear that all aspects SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 14 required by the standards were covered during supervision as the records seen were not detailed therefore the manager was unable to ensure that all staff were competent to carry out their jobs. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 15 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 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x 2 x x x x 3 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 2 x x SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 16 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP11 OP15 OP21 Regulation 15 16 23 Requirement Ensure the wishes of the service users regarding death and dying are recorded. Ensure that a supper is always offered to all service users. Ensure the bathing facilities meet the needs of the service users. consider installing a walkin-shower to meet these needs. Ensure the staff complement meets the needs of the service users by providing appropriate senior staff to take charge of the shift. Ensure that all mandatory training is carried out and up to date for all staff. Ensure staff supervision is carried out every 2 months for all members of staff. (old timescale 31.3.05) Ensure all radiators in close proximity to beds are guarded. (old timescale 1.4.05) Timescale for action 1.8.05 1.8.05 1.10.05 4. OP27 18 1.8.05 5. 6. Op30 OP36 18 18 1.8.05 1.8.05 7. OP25 13 14.7.05 SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 17 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 Op28 Good Practice Recommendations Ensure there are 50 of care staff trained to NVQ level 2. SANDROCK HOUSE J55-J07 S7971 sandrock House V215960 090605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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