Inspection on 30/08/07 for Sandy Lodge

This inspection was carried out on 30th August 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandy Lodge 14/02/06

Sandy Lodge 22/03/05

Sandy Lodge 07/12/04

Sandy Lodge 16/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Sandy Lodge Southchurch Avenue Shoeburyness Essex SS3 9BA Lead Inspector Michelle Love Unannounced Inspection 30th August 2007 09.55 Sandy Lodge DS0000015559.V344579.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 Sandy Lodge DS0000015559.V344579.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. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandy Lodge Address Southchurch Avenue Shoeburyness Essex SS3 9BA 01702 298064 01702 298064 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) Estuary Housing Association Limited Naaz Bibi Seebaruth Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Excluding any person who is liable to be detained under the provisions of the Mental Health Act 1983 12th September 2006 Date of last inspection Brief Description of the Service: The cost of residential care at this purpose built home is £1397.08 per week. The house is situated within a residential area. There are seven single rooms and one double room. There is no passenger lift and bedrooms are situated on both floors. There is a living room, fitted kitchen and dining room. Assisted toilets and bathrooms are available as are a full range of moving and handling equipment. The home has a small garden. The home is situated in a residential area of Shoeburyness. Shops are located nearby and a bus route runs regularly. The home has an up to date Statement of Purpose and Service Users Guide and this is displayed within the main entrance hall of the home. A copy of the last inspection report is readily available and easily accessible for interested parties. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken by Michelle Love, Regulation Inspector, over a period of approximately 5.5 hours. The inspection was conducted with the assistance of two senior support workers and support staff. As part of the process a number of records relating to individual residents and support staff were examined e.g. care plans, risk assessments, healthcare records, staff employment files, staff training records etc. Additionally the homes medication systems were observed and records reviewed. A tour of the premises was undertaken throughout the day. During the visit two senior support workers and three members of support staff were spoken with. As a result of resident’s communication difficulties, the inspector observed residents interaction with staff and their non-verbal communication and cues. Six staff survey forms were left for staff to complete and all were returned to the Commission for Social Care Inspection following the site visit. It was positive to note that 22 out of 25 standards assessed were fully met, and only 3 statutory requirements and 3 recommendations have been made as a result of this inspection. What the service does well: What has improved since the last inspection? Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 6 It is difficult to ascertain what has improved since the last inspection, however good care practices and standards have been consistently maintained. 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. Sandy Lodge DS0000015559.V344579.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 Sandy Lodge DS0000015559.V344579.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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear information setting out its aims, objectives and services provided. Prospective residents are formally assessed prior to admission. EVIDENCE: The home has a Statement of Purpose and Service Users Guide, which were reviewed in April and July 2007. Both documents are detailed and comprehensive and the Commission for Social Care Inspection recognises that for all residents residing at the care home, none would understand either document if they were devised in a written (simple language) and pictorial format or within another medium e.g. talking book or DVD. The home has not had any new residents since the last inspection. Sandy Lodge DS0000015559.V344579.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive system/format for recording resident’s health, social and personal care needs. EVIDENCE: On inspection of two individual care plans, documentation was observed to be detailed and comprehensive and included information relating to individual’s health, social and personal care needs. Each care plan was observed to have been reviewed and reflected changes to their care needs where appropriate. Evidence suggested where possible that individual residents and/or their representative had been involved and consulted within the care planning process. It was positive to note that the assessment process made reference to individual’s strengths and areas of specific need. Clear guidelines for staff so as to deliver person centred care were recorded. Risk assessments were devised for all areas of assessed risk, and these were informative, comprehensive and detailed. Where individual resident’s exhibited Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 10 `lively` or inappropriate/aggressive behaviours, clear behavioural indicators were completed recording the specific nature of the behaviour, known triggers and staff interventions required. Daily care records were written after each shift and recorded how residents spent their day and staff interventions. Sandy Lodge DS0000015559.V344579.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the care home receive appropriate daytime activities and opportunities to participate in leisure pursuits. The menu is varied and support staff are sensitive to the needs of those residents who require assistance. EVIDENCE: Records indicate some residents attend local formal day care provision e.g. Heston Lodge, Bathseba, Viking House and Avro Adult Training Centre during the week. A structured activity programme was available and included both `in house` and community based activities for all residents relating to going out for a drive, theatre trips, pub outings, adult education, sensory sessions, arts and crafts etc. Each resident has their own activity folder and trips enjoyed over recent months included Woburn Abbey, London and the London Eye, Boat Trip, London Aquarium, Tropical Wings/Marsh Farm and Madam Tussuards. The Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 12 inspector was advised that two people enjoyed a short holiday to Butlins and others have participated within a variety of day trips according to their needs and personal preferences. The home operates an `open` visiting policy, whereby residents can receive their friends/members of family at any reasonable time. Communication with families is maintained and welcomed. The home operates a rolling six week menu. The menu was observed to offer variety and choice for residents and the inspector was advised that alternatives to the menu are always available. The senior in charge of the shift reported that the menu is flexible and is not stuck to rigidly. On the day of inspection, residents were seen to have a meal that looked both plentiful and appetising. It was positive to note that support staff also sit and eat their meal at the same time as residents and this assists socialisation. On Saturday’s residents are offered `brunch`. Sandy Lodge DS0000015559.V344579.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs of individual residents are clearly recorded and evidence a range of access to healthcare professionals and services. The homes medication procedures and record keeping are good. EVIDENCE: The healthcare needs of individual resident’s, is well recorded and appropriate interventions and support is available. Records indicate residents have access to a range of healthcare professionals, for example Community Nurses, Consultant Psychiatry, GP etc. Personal care for individual residents was carried out in private and support staff, were seen to be respectful and sensitive to resident’s needs. The home provides appropriate equipment to assist residents. This refers specifically to hoists, special assisted baths and custom made wheelchairs. The home’s medication procedures and practices were seen to be safe. No residents within the home are able to administer their own medication. PRN (as and when required) medication protocols were noted to be detailed and Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 14 comprehensive. The senior in charge of the shift was advised to ensure that the list of those staff deemed competent to administer medication needs to be reviewed and updated. Additionally where packets/bottles of medication are opened, these should be dated and signed. A random sample of staff training files were examined and evidence suggested staff have up to date training. Some members of staff have undertaken training relating to the administration of Rectal Diazepam. The registered provider must ensure that records indicate that the person who has completed this training is deemed competent to administer the medication. Sandy Lodge DS0000015559.V344579.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints and safeguarding procedures protect those people living at Sandy Lodge. EVIDENCE: The home has received no complaints and has not been subject to any safeguarding issues since the last inspection. Information on how to make a complaint is displayed within the main entrance hall and the home has a copy of Southend Borough Councils Adult Protection Policy and Procedure. Records indicate that support staff have received training relating to safeguarding and there is a DVD training pack available on this subject, which is easily accessible. Sandy Lodge DS0000015559.V344579.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an appropriate environment that is appropriate to the needs of the people who live there. EVIDENCE: Residents live in safe, comfortable and homely environment, which is decorated tastefully. Individual resident’s bedrooms are personalised and reflect resident’s personal preferences and interests. Some bedrooms also had specialist sensory equipment in situ. All areas of the home were observed to be clean, tidy and odour free. The homes laundry area was well maintained. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 17 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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is unclear as to whether or not there are sufficient numbers of staff to meet the needs of residents at all times. The service has an adequate recruitment procedure, however this does not always include information relating to agency staff. The registered provider is committed to provide all staff with relevant training however there must be a rolling programme, which ensures staff receive refresher/updated training as necessary. EVIDENCE: The senior in charge on the day of the site visit, advised the inspector that staffing levels should be 4 staff between 08.00 a.m. and 20.00 p.m. and 2 staff between 20.00 p.m. and 08.00 a.m. each day. Staff rosters were examined for the period 30.7.07 to 30.8.07 inclusive. The senior in charge was advised to avoid the use of white correction fluid and to ensure the full names of all staff, including agency staff are recorded on the roster. The inspector was advised that one resident is contracted to receive a small number of 1-1 hours by support staff. The senior in charge was advised that as part of good practice procedures the roster should clearly define who is responsible to undertake this role on any given shift. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 18 The rosters indicate on a few occasions that staffing levels have not always been maintained as detailed above. It is unclear as to why this has occurred and the Commission for Social Care Inspection must be formally notified as part of Regulation 37 Notifications. The staff rosters indicate the majority of staff complete, 08.00 a.m. to 20.00 p.m. shifts but have appropriate off duty days. Some staff were noted to work between 60-63 hours per week. This must be monitored to ensure support staff, remain competent to undertake their role. Staff surveys recorded a lot of emphasis is placed by the registered provider, for staff to complete cleaning/domestic tasks as well as providing quality care to residents. Staff feel, this can be detrimental to the actual time spent with residents and would like the registered provider to consider employing a cleaner and for some administrator hours to be provided throughout the week. Recruitment files for three members of staff were inspected and all records as required by regulation had been sought. The staff rosters for the period 30.7.07 to 30.8.07 inclusive evidenced the use of agency staff at Sandy Lodge. Agency profiles were not available for all people who had worked at the care home during this period. Information made available must include evidence of training, experience and include confirmation that all other records as required by regulation have been received and verified by the agency. A record of induction was not available for all agency members of staff. It was positive to note that an `agency information pack` has been devised by Estuary Housing Association and provides general/generic information about residents and their daily routines throughout the day and night. Additional information includes resident’s physical health and wellbeing. On inspection of a random sample of training records, these suggested the registered provider is committed to providing a range of training for all staff, however some staff require refresher/updated training relating to food hygiene, manual handling, health and safety, first aid, infection control etc. Actual supervision records could not be accessed, however a supervision tracker was available and this indicated, support staff had received regular formal supervision in line with the Care Homes Regulations and National Minimum Standards. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 19 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required experience and competence to run the care home. EVIDENCE: The manager was not present at this inspection, however senior staff, were observed to be more than competent to run the home and to advocate on behalf of residents in her absence. From information recorded at previous inspections, the manager has managed the home for the past three years and is a qualified nurse. Staff surveys consistently recorded the manager is supportive and staff found her to be approachable. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 20 Resident meetings are undertaken and the use of `flash cards` is used so as to communicate effectively with individual residents and to seek their views and wishes. Evidence of regular staff meetings being undertaken were available. A random sample of safety certificates were examined at the last inspection and deemed appropriate, therefore these were not inspected on this occasion. A random sample of wash hand basins were tested to ensure that hot water emitted was at the safe temperature. No health and safety issues relating to this were highlighted at this visit. Sandy Lodge DS0000015559.V344579.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 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 3 3 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 3 X X 3 X Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 22 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. 1. 2. Standard YA33 YA34 Regulation 18(1)(a) 19 Requirement Ensure there are sufficient staff on duty at all times to meet the needs of residents. Ensure that robust recruitment procedures are adopted and maintained at all times. This refers specifically to agency staff deployed to work at the care home. Ensure that all staff working at the care home receive appropriate training. This refers to staff receiving refresher/updated training. Timescale for action 30/08/07 07/10/07 3. YA35 18(1)(c) 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA20 YA20 YA33 Good Practice Recommendations Ensure the list of staff deemed competent to administer medication to residents is up to date. Ensure where packets and bottles of medication are opened, these are signed and dated. Ensure that the staff roster details the full names of all DS0000015559.V344579.R01.S.doc Version 5.2 Page 23 Sandy Lodge staff working at the care home on any given shift. This refers specifically to agency staff deployed to work at the care home. Sandy Lodge DS0000015559.V344579.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. 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