Inspection on 04/01/07 for Sandtoft

This inspection was carried out on 4th January 2007.

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 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

Sandtoft 10/09/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sandtoft 70/72 Alderley Road Hoylake Wirral CH47 2BA Lead Inspector Les Smith Key Unannounced Inspection 09:00 4th January 2007 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 Sandtoft DS0000067373.V302890.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. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandtoft Address 70/72 Alderley Road Hoylake Wirral CH47 2BA 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) 0151 632 1952 Sandtoft Care Home Ltd Mrs Yvonne MacDougall Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Sandcroft is registered to provide personal care to 22 older people. The home is a three-storey building with access via stairs and a passenger lift to all floors. There are 22 single bedrooms 16 of which have en-suite facilities. Five rooms are of double room size. Communal facilities comprise a lounge, dining room, conservatory and a quiet library area. Two bathrooms and a shower room are provided and assisted bathing facilities are available. There is a ramp access to the home for wheelchairs or residents who cannot manage the steps to the front of the building. The home is situated in the residential area of Hoylake close to the beach and promenade. Access to public transport and the centre of Hoylake is close by. Fees at Sandtoft range between £342 and £370 depending upon the room occupied. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over a period of eight hours in the presence of the registered manager and the provider. During the visit care records and associated documents, staff files, management records were examined. Discussions were held with the provider, manager, residents and visitors to the home. The home has a very homely atmosphere and staff were observed going about their duties in a cheerful manner and clearly had a good rapport with the residents. Relatives spoken to were very complimentary in relation to the service provided with comments such as ‘the food is excellent’, ‘anything mum does is of her own choice, everything is very flexible here’, ‘the home was exceptionally helpful in arranging for mum to have regular visits from the priest’ and ‘I would like to see more activities to provide more stimulation’. The home is undergoing significant changes due to the change of ownership in June 2006 and the change process is ongoing. What the service does well: What has improved since the last inspection? What they could do better: Medication management must be improved to meet the required standard. The recording and management of controlled drugs is a particular concern. Staff responsible for medication administration and management must receive appropriate training to ensure that they have the knowledge and competency in this essential area. The range of activities available to residents is limited and does not take account of individual interests and needs to be expanded to provide a programme that is all inclusive of individual needs and interests. The security of confidential documents such as care files needs improvement. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 6 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. Sandtoft DS0000067373.V302890.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 Sandtoft DS0000067373.V302890.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have sufficient information to make an informed decision about where they wish to live and be confident that their needs will be fully assessed prior to accepting a place at the home. EVIDENCE: The Statement of Purpose and Service User Guide have been reviewed and revised since the change of ownership earlier this year. Both documents contain the required information Examination of files showed that appropriate contracts or Statement of Terms and Conditions are issued and copies kept. Copies of the contracts and other confidential documents are currently being kept on the care files and are available to be seen by all staff members. Contracts and other confidential information should be kept separately with restricted access and it is strongly recommended that this be remedied. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 9 Prospective residents have an assessment carried out by the manager prior to being offered accommodation at Sandtoft. The pre-assessment documentation is in the process of being changed to the new corporate documents provided by the new owner, which will significantly enhance the assessment process. Evidence was seen to show that information from the relevant social worker and other health care professionals is obtained in order to inform a comprehensive assessment. The home is equipped with a range of facilities to meet residents’ needs including a passenger lift, handrails, assisted bathrooms and handrails. Prospective residents and their representatives are welcomed at the home at any time to assess the quality, facilities and general suitability of the home and are welcome to visit as often and for as long as they wish. Sandtoft does not provide intermediate care. Sandtoft DS0000067373.V302890.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A collaborative care planning process supports and promotes residents health and wellbeing but medication management needs to be strengthened to meet best practice guidelines. EVIDENCE: A selection of care files were reviewed and showed that each resident has an individualised care plan in place. The care plans seen contained appropriate risk assessments and evidence of regular review. A new corporate care planning system is currently being implemented and this will be a significant improvement in comprehensiveness and consistency. Residents’ health care needs are fully met with details of referrals to the multi-disciplinary team whenever necessary in accordance with resident’s needs and outcomes are documented. Medication management does not meet best practice guidelines and procedures need strengthening to promote the health and safety of residents. Three examples were seen of residents self-medicating with various medicated creams and inhalers, which promotes their independence. However, Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 11 appropriate risk assessments had not been carried out and one of the creams is required to be kept in a refrigerator. It is important that self-medication is encouraged but risk assessments must be carried out and monitored. Specimen signatures were not available for those members of staff who administered medications. Handwritten entries on MAR (Medication Administration Record) sheets were unsigned. Such handwritten entries must be signed and countersigned by a second person. Medications prescribed on an as and when required basis have no guidelines as to when the medication should be given. The management of controlled drugs is particularly poor. Balances of controlled drugs were checked and found to be correct. However, the recording of controlled drugs is poor with entries for two different strengths of a controlled drug on a single page. A new box of a controlled drug was appropriately stored but had not been recorded in the controlled drug register. Initial checks showed a shortfall of one tablet but it was found that a single tablet had been removed from the new box held in the cupboard. It is clear that the required checks on balances at each administration are not being carried out. Training in medication management could not be evidenced for staff responsible for medication administration and must be undertaken. Given the shortfalls in this area and the controlled drugs in particular, it is required that staff members responsible for the management and administration of medications undergo appropriate training in all aspects of medicines management. Staff must only be allowed to administer medication when they have been assessed as competent to do so. The delivery of care was observed throughout the course of this visit. Care staff was seen to address and treat residents with respect and privacy was maintained whilst personal care was carried out. Sandtoft has appropriate policies and procedures in place to promote the treatment of residents and their families with sensitivity and respect at the end of life. Sandtoft DS0000067373.V302890.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have choice and flexibility in how they spend their day and participate in a limited range of activities and social recreation thereby promoting independence and wellbeing. EVIDENCE: Sandtoft does not employ an activities co-ordinator but a limited range of activities and social recreation is provided by the home. Film shows, bingo, pampering and exercises together with regular visits from an accordion player are the main activities provided. A mobile library visits the home on a regular basis. Relatives spoken to stated that ‘more could be done to provide stimulation for the residents’. Many of the residents at Sandtoft have low dependency and go out with friends and family for meals, theatre visits and utilise the facilities in the local community. Consideration must be given to those residents who for whatever reason cannot avail themselves of the external activities and the employment of a dedicated activities co-ordinator would enable a programme of activities to be established taking into account the individual interests and hobbies of the residents. The home has a policy of open visiting with friends and family welcome at any reasonable time and to stay as long as they and the resident wished. Visitors Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 13 were observed to be arriving at the home throughout the day and residents were able to see their guests in one of the communal areas or in their own rooms as they wished. Daily routines are kept as flexible as possible in order to maximise individual choice and autonomy. Residents spoken to were complimentary about the assistance they received from the staff in relation to their personal choice, which was encouraged at all times. The home maintains records of the meals provided each day, which shows that alternative meals are always available in accordance with residents’ personal preferences. Residents spoken to were highly complimentary about the quality of the meals at Sandtoft. The lunchtime meal on the day of this visit comprised three courses all of which looked appetising and well presented. The low waste demonstrated residents’ enjoyment of the meal. Sandtoft DS0000067373.V302890.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be certain that complaints are taken seriously and that residents are protected from abuse. EVIDENCE: There have been no complaints to the home or directly to the CSCI since the previous visit. The home maintains a record of all complaints that includes details of any investigations carried out and the outcome. It is recommended that a record be kept of any verbal complaints made together with details of actions taken in order to promote openness and transparency. All residents are registered on the electoral roll and have to opportunity to exercise their legal rights. The home has policies and procedures in place and a copy of the Wirral adult protection procedures. Staff have attended training on adult protection and demonstrated an awareness of the procedures to follow in cases of alleged or suspected abuse. Sandtoft DS0000067373.V302890.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sandtoft is well maintained and furnished to a good standard that promotes a safe, homely and comfortable environment for residents. EVIDENCE: A tour of the home was made accompanied by the provider who was visiting the home on the day. The home is generally well maintained and the areas highlighted in the previous report have been redecorated. New windows have been installed in the rooms on the top floor at the rear of the home, which have integral window restrictors. There are adequate toilet and bathing facilities throughout the home. Hot water outlets are regulated and maintained at a maximum of 43 degrees centigrade, which was confirmed by the regular checks documentation. The kitchen and laundry were both clean and well organised. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 16 Residents’ individual rooms are light and spacious and those seen showed a good level of personalisation with furniture and memorabilia. The home has appropriate aids and equipment such as assisted bathing facilities, handrails and a passenger lift in place. The home employs sufficient domestic staff and on the day of this visit the home was clean, fresh and hygienic. Policies and procedures are in place to promote a high standard of cleanliness and hygiene. Sandtoft DS0000067373.V302890.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are recruited via robust procedures and deployed in sufficient numbers and skill mix to promote and support residents’ health, safety and welfare. EVIDENCE: Examination of the duty rosters showed that there were sufficient staff members on duty most of the time to meet the assessed needs of residents. It is recommended that duty rosters show the full name and position held. The manager confirmed that only two care staff were on duty for the period 1600 to 2200 and that they were required to prepare the tea for the residents as the kitchen assistant did not come on duty until 1730. Whilst two carers are considered adequate to meet residents’ needs whilst the tea was being prepared only one carer was available to assist residents. This is not good practice and the practice of care staff preparing food and carrying out the care function at the same time compromises both residents safety from both care and infection control aspects. The provider was not aware of this situation and following discussion the issue was addressed immediately and will not occur again. Currently, there are eleven out of 16 care staff holding a minimum of the NVQ level 2 qualification which equates to 68 and a further two members of staff are studying for the qualification. One member of staff is actively studying for NVQ 3. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 18 The home has a low turnover of staff, which promotes continuity of care. A selection of staff personnel files were examined and showed that all the required information and documents were in place. Some of the documents such as the application form are lacking in the information required from an applicant e.g. previous employment history. Discussions with the provider showed that it is planned to introduce the corporate paperwork, which will address this, and an undertaking was given that the new documentation will be put in place as soon as possible. Evidence of staff training was seen but manual-handling training was outstanding for all staff. Training in manual handling was arranged for the staff at Sandtoft by the provider to take place within the following two weeks. There is a qualified first-aider on duty at all times. It is strongly recommended that a mechanism be put in place to identify in a timely manner when training is due. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 19 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): 31,32,,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ at Sandtoft benefit from an experienced and competent management focussed upon the best interests of residents. EVIDENCE: The registered manager has managed Sandtoft for several years and is continuing to manage the home for the new provider. Holding the NVQ 4 in management qualification she is currently working towards the NVQ level 4 in care and registered managers award. The home holds the Investors in People award and has quality assurance systems in place. Staff meetings are held regularly and staff supervision is in place and carried out at least six times per year. Quality questionnaires are distributed each year to residents, relatives and relevant health care Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 20 professionals to enable evaluation of the service provided and action to be taken on any concerns or suggestions for improvement made. A sample of residents’ monies were checked and found to be correct. Receipts for expenditure are kept. As at previous visits the care files are kept on an open shelf in the office, which cannot be locked. It is not possible to ensure that the office is never left unattended. A further concern is that there are other documents in the office such as staff supervision records, which should be stored securely. It is essential that confidential records are held securely and appropriate arrangements for secure facilities must be put in place. Examination of records showed that mandatory training requirements with the exception of manual handling as previously mentioned have been met. Fire alarm and emergency lighting checks are carried out on a regular basis and an up to date fire risk assessment was seen. Relevant maintenance contracts, checks and inspection certificates were seen for: Fire alarm system Fire extinguishers Portable appliance checks Electrical installation Emergency lighting system Gas safety certificate Passenger lift Assisted baths and hoists Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 X 3 3 2 3 Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 The registered person must ensure that medication policies and procedures be reviewed in line with Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicines management. The registered person must ensure that staff authorised to administer medication receive appropriate medicines management training and have an assessment of their competence, prior to performing these tasks. The registered person shall ensure that service users are consulted about the programme of activities arranged by the home and provide facilities for the provision of recreational activities based upon individual needs and interests The registered person shall ensure that records that contain confidential information are kept securely Timescale for action 28/02/07 2 OP9 13(2) 28/02/07 3 OP12 16(2)(m) 28/02/07 4 OP37 17(10(b) 28/02/07 Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 23 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 OP12 Good Practice Recommendations It is recommended that that consideration be given to the provision of a dedicated activities co-ordinator. Sandtoft DS0000067373.V302890.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Sandtoft DS0000067373.V302890.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. 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