Inspection on 11/06/07 for Sandrock House

This inspection was carried out on 11th June 2007.

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

Sandrock House 12/12/05

Sandrock House 10/06/05

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 South Yorkshire DN4 7AA Lead Inspector Ros Sanderson Key Unannounced Inspection 11th June 2007 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 DS0000007971.V330643.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 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. DS0000007971.V330643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandrock House Address 53 Bawtry Road Bessacarr Doncaster South Yorkshire DN4 7AA 01302 535634 01302 535634 NONE 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) 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 DS0000007971.V330643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th 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. The home is in Bessacarr, Doncaster and is close to local amenities. Sherwood Care Homes Ltd owns the home. All bedrooms are single with en-suite toilet facilities except for one. Accommodation is provided over two floors. The upper floor is accessed by a stair lift. There are two pleasant lounges and a dining area. The gardens are well kept and people living at the home enjoy sitting out. People who are interested in staying at the home are given information about the home in the form of a brochure. All people that come to live at Sandrock House are provided with a Service User Guide. The latest inspection report from the Commission for Social Care Inspection is available in the home. The current fees charged are £385.00 per week. Additional charges are made for hairdressing, chiropody and personal toiletries and newspapers. DS0000007971.V330643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on a pre inspection questionnaire Comment cards returned from 1 staff member and 1 relative. A visit to the home carried out by one inspector. A site visit was carried out and lasted five and a half hours. Five service users, two visitors and three staff were spoken with. Records relating to people living at the home, staff and the management activities of the home were inspected. Observation took place of care practices in the home, where appropriate. This helped the inspector to gain an insight of what life is like at Sandrock House for the people that live there. The manager assisted the inspector during the day. The responsible individual, Mrs Khalid, was also available for part of the day. The manager and Mrs Khalid were given feedback from the inspection at the end of the day. What the service does well: People that come to live at Sandrock House have their needs fully assessed before moving in. People are only admitted when the staff are confident that they are able to meet their needs. People are encouraged to keep in contact with friends and family. Staff at the home keep people informed of how their relative is doing. One relative said, ‘We visit on most days and are able to come at anytime, we are always made to feel welcome’. Another said, ‘I am always kept informed of any changes and also of anything going on in the home’. There is a newsletter that is published every two months. The food provided is good and appreciated by people. The cook visits people and finds out what they like and don’t like. She keeps the menus under review. Mrs Khalid, a director, and the manager, Joyce Richardson, promote a culture within the home of openness. Any complaints or concerns are dealt with effectively and promptly. DS0000007971.V330643.R01.S.doc Version 5.2 Page 6 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. DS0000007971.V330643.R01.S.doc Version 5.2 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 DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 is not applicable People who use the service experience good quality outcomes in this area. People are given sufficient information about the home to help them make an informed choice to live there. People have their needs assessed and only move into the home if their needs can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The Statement of Purpose was available in the home and all people living at the home have a copy of the Service User Guide. These documents contained all the relevant information required. This means that people are made aware of the services available to them in the home. DS0000007971.V330643.R01.S.doc Version 5.2 Page 9 All people wishing to live at this home have a full assessment of their needs carried out by the home manager. These were seen in the individual care plans. They were comprehensive and evidenced that the home was able to meet the needs of the people that move into Sandrock House. All prospective residents and their families are invited to look round the home, and spend time at the home before moving in. This ensures that their needs can be met and that they are happy with the home. People spoken with confirmed that this happens. DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience adequate quality outcomes in this area. Fuller discussions with people about their care needs would ensure that these are met in a way that is agreed and acceptable to people. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The care records of three people were looked at and all had comprehensive care plans in place. These plans gave good and clear information to staff about how the assessed needs of people are to be met. One person commented, ‘The staff are good, I have no complaints’. DS0000007971.V330643.R01.S.doc Version 5.2 Page 11 People were not aware that written records were held about them and that they could look at these if they wished. Care plans were reviewed monthly and updated as needed, however, people receiving care and their relatives said they were not involved in reviews. Involvement in this process would help to make sure that people were fully involved in identifying and planning for their care needs. One person spoken with said that, as they now needed more help, they had requested this. A member of staff had discussed this with them and additional help had been agreed. The person said, ‘I need extra help now and I thought that this had been agreed but staff still don’t come.’ There is currently only one bath that is available for use. This is a ‘Parker’ bath that is accessible for all people to use. There are a further two bathrooms in the home, however one has a half length bath in and is not used and the other is a low bath with a bath seat in to help people. At the time of the inspection, this seat was not in use as it was broken. One person had said, ‘I would like to have a bath more often or even a shower’. A relative said that there does not always seem to be enough hot water available. During the morning the water temperatures were checked and were quite low (36°C) but by lunchtime the temperature was around 43°C; that is acceptable. The manager said that people had baths during the afternoon or evening. The lunchtime medication round was observed. The medication trolley was not taken round at lunchtime. The drugs were dispensed in the office and then taken to each person. The member of staff, however, did not make sure that the person took the tablets before returning to the trolley to get the next person’s. This had been a problem highlighted in the staff meeting when it was recorded, ‘Please make sure people take their medications…they have been found in people’s rooms the following day’. In addition to this, a member of staff had been disciplined for not using the medication trolley and not supervising people taking their tablets. The medication records showed that some people had had their medication stopped by their GP but it had not been recorded when this had happened, also some people had had tablets stopped but this was not written on the chart and the drugs were still in the medication trolley. This could mean that people are given tablets that they are no longer prescribed. Controlled drugs were all accounted for and stored appropriately. A relative said, ‘It is important that gets their medication safely and the staff always make sure that this happens’ DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good quality outcomes in this area. People are satisfied with the lifestyles that they lead. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: An activity co-ordinator works with care staff to provide activities for service users each day. People’s likes and dislikes regarding activities have been obtained and recorded to ensure the appropriate activities are provided. The home continues to also have outings and entertainment in addition to this. Service users commented that the activities and entertainment were very good. Contact with family and friends is actively encouraged with the home arranging various activities that family and friends are able to attend. One relative said, ‘We visit on most days and are able to come at anytime, we are always made to feel welcome’. Another said, ‘I am always kept informed of any changes and also of anything going on in the home’. DS0000007971.V330643.R01.S.doc Version 5.2 Page 13 Visiting clergy give communion to those people who wish to receive it. Lunch was observed; the food was nicely presented with choices given. There is a varied menu that is reviewed regularly to ensure people’s choices are taken into consideration. The cook visits people once a week to make sure that people are satisfied with the food. Service users spoken to said the food was good. Comments included, ‘The food is quite nice’. A relative said that the food was good and had helped her relative gain some much needed weight following their admission. DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area. People are listened to and feel safe. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There is a simple easy to follow complaints procedure. It is accessible to all people living at the home, their relatives, visitors and staff. People said if they wished to make a complaint they would approach the manager or Mrs Khalid, the responsible individual, as she always listened and took all concerns seriously and acted on them. One relative had been very impressed with the response from Mrs Khalid following a concern they had raised. People felt that any issues would be seen to quickly. The protection of vulnerable adults policy provides an easy to follow guide with all relevant contact numbers included. Staff were aware of adult protection and had received the necessary training to safeguard the service users. They were clear about their responsibilities in this area. This helps to ensure that people would be protected and any issues arising correctly reported. DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 People who use the service experience adequate quality outcomes in this area. People are provided with a comfortable environment in which to live but would benefit from additional bathing facilities. We have made this judgement using a range of evidence, including a visit to the service. DS0000007971.V330643.R01.S.doc Version 5.2 Page 16 EVIDENCE: The home is well maintained with a programme of routine maintenance. There have been many improvements made to the environment since the last inspection. This includes decoration of individual bedrooms and the provision of new seating for the lounge. One person had commented that people smoked in the dining area following meals and some people did not find this acceptable. This had been passed on to Mrs Khalid who had immediately made alternative arrangements for people who wished to smoke. These arrangements are now acceptable to all people living at the home. The grounds are kept tidy and safe and accessible to service users. It remains outstanding that there are insufficient bathing facilities in the home. The use of unguarded radiators has not been looked at to assess the risk to people. Most radiators have a thermostatic control fitted but this does not apply to all of them. One relative said, ‘I always make sure there is a towel over the radiator in the toilet as they hold on to it to steady themselves and sometimes it is hot’. DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area. People are cared for by staff that are safe and well trained. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The skill mix of staff is very good with a low staff turn over. Since the last inspection more senior carers have been identified so that there is always a senior on duty. This means that people living at the home always have access to an experienced member of staff. Three staff files were looked. The files contained all the required information and showed that robust recruitment procedures were followed. This goes towards ensuring that people are protected by the procedures. The staff training files shows that staff are up to date with mandatory training. All new staff complete the ‘common induction standards’ under the supervision of the manager. One recent starter said, ‘I have completed my induction and worked with somebody until this was complete’. 50 of care staff have completed an NVQ in care at level 2 or above. DS0000007971.V330643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People who use the service experience good quality outcomes in this area. The home is managed in the best interests of people living there, and the staff. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager has completed her NVQ level 4 in care and her Registered Manager’s Award since the last inspection. Mrs Khalid, the responsible individual, visits the home regularly and offers her support and guidance. People feel they can speak to both people and that their opinions are valued. DS0000007971.V330643.R01.S.doc Version 5.2 Page 19 Mrs Khalid visits the home and carries out visits to check on quality issues. Written records are kept of these visits. The manager carries out regular quality monitoring. This includes satisfaction with food and activities in the home. There are regular residents’ meetings gaining views and feedback to ensure the home is run in the best interests of service users. A newsletter is published every two months. People are encouraged to look after their own affairs. The manager is sometimes asked to look after some personal monies for people. A selection of records relating to this were checked and found to be correct. Written records are kept of all transactions and receipts are kept and the money is stored in a secure facility. Supervision of staff is carried out every two months. At these meetings, the aims and objectives of the home are discussed and any training needs identified. Staff spoken with found this useful. The home has a health and safety policy. Safe working practices are ensured through regular staff training on all health and safety issues. Staff confirmed that training was carried out. The manager has provided information that shows all health and safety certificates are up to date. DS0000007971.V330643.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 1 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000007971.V330643.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement Medication records must be kept up to date at all times. Staff must administer medication in accordance with the policy and procedure of the service. This includes supervision of people when taking their prescribed medication. This will ensure that people receive their prescribed treatments safely. People receiving care should be fully involved with identifying needs and planning how these are to be met. Any reviews of the care plans must be made following consultation with the person involved where possible. This will ensure that people have their needs fully identified and met in away that is agreed with them. Ensure the bathing facilities meet the needs of the service users. Consider installing a walkin-shower to meet these needs. Timescale for action 30/06/07 2. OP7 15(2) 01/09/07 3. OP21 23 01/09/07 DS0000007971.V330643.R01.S.doc Version 5.2 Page 22 Previous timescale of 1.10.05 and 1/3/06 not met A plan with clear timescales must be forwarded to the Commission for Social Care Inspection to show how you intend to provide suitable and sufficient bathing facilities at the home. Risk assessments must be put in place to assess the risk to people from unguarded radiators. Control measures must be put in place to reduce any identified risk. This will help to ensure people’s safety. 4. OP38 13(4) 30/06/07 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 OP21 Good Practice Recommendations Consideration should be given to providing a shower facility for people’s use. DS0000007971.V330643.R01.S.doc Version 5.2 Page 23 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 DS0000007971.V330643.R01.S.doc Version 5.2 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. 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