Inspection on 02/04/08 for Sandybrook House

This inspection was carried out on 2nd April 2008.

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

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sandybrook House Sandy Lane Lower Darwen Lancashire BB3 0PU Lead Inspector Mr Graham Oldham Unannounced Inspection 09:30 2nd April 2008 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 Sandybrook House DS0000071197.V356761.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. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandybrook House Address Sandy Lane Lower Darwen Lancashire BB3 0PU 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) 01254 660050 01254 660050 info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Mrs Sharon Wilkinson Care Home 25 Category(ies) of Dementia (25), Mental disorder, excluding registration, with number learning disability or dementia (25) of places Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender: - Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental disorder, excluding learning disability or dementia. - Code MD The maximum number of people who can be accommodated is: 25 Date of last inspection Brief Description of the Service: Sandybrook House is a detached purpose built house situated near to Blackburn and Darwen Town centres. There is an easily accessed bus route to both towns. The home is operated by Prime Life Ltd, a national company. There are several shops and facilities locally including a supermarket, post office and sandwich bar. The home offers a variety of communal space such as a music lounge, movie lounge, dining room and several seating areas. There are 25 bedrooms all with en-suite toilet and washbasin facilities, 11 have a bath, shower or a combination of both. The main bathrooms and showers have easy access for the disabled. Outside space is accessible to the disabled and enclosed for the safety of residents. There is ample car parking space to the front of the property. A statement of purpose and service users guide is available for residents or their families to be informed of the facilities and services the home provides. The fees for Sandybrook House range from £334 to £455 per week. This does not include some aspects of hairdressing or personal toiletries. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service are experiencing good quality outcomes. This unannounced key inspection, which included a visit to the service, took place on the 2nd and 3rd of April 2008. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Three residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Two staff members were questioned about the care of the resident’s case tracked. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building was conducted. Four relatives returned CSCI comment cards. Three thought they always received information to help make decisions. Two commented and said, 1. All the staff at Sandybrook House are very friendly and listen to any questions I’ve had. The home immediately feels like a ‘home from home’ and if I have had any queries they could not answer they have got back to me promptly. 2. They seem to be very helpful if you ask any questions. All four thought the care home always met the needs of their relative. One said, “All the staff have my dad’s best interests in mind. He is spoken to with respect and he is maintaining his independence”. Three thought they were always kept up to date with important issues and one usually. One said, Dads admission and then discharge from hospital was properly discussed and staff attended a consultation to discuss his future ongoing care requirements. All four thought care was always as expected or agreed. All four thought staff always had the skills to meet the needs of residents. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 6 Three thought the care service always met the diverse needs of residents and one usually. Three were aware of how to make a complaint and one did not. This relative said the home always responded to any concerns raised, as did the three other relatives. All four thought the care service helped residents live the life they chose. One said, Given Dads capabilities he does seem genuinely happy and well cared for. Relatives commented on what the home does well. 1. Flexible visiting. Environment, staff, residents and relatives are all together and it’s a lovely atmosphere. 2. They always do well looking after the people they have to look after and do a good job. 3. 1st class service. 4. They look after people with great care and attention. One relative commented on how the home could improve. “As Dad has only been with Sandybrook for a short time I have not noticed any need for improvement. I would like to be notified and feel I would be if any changes are implemented. I feel confident Dad is getting the best possible care”. No relative wished to talk to an inspector. The positive information supplied showed relatives were satisfied with the care service. Five staff members returned CSCI comments cards. All five thought they were given up to date information for the people they cared for. All five thought employment checks were robust. One said “I did not start work until my CRB came back”. All five thought the induction process was conducted very well. One said, everything I needed to know about what the job entailed. All five thought training was relevant to their role, helped them understand the diverse needs of residents and kept them up to date. Two commented. 1. Management keep me up to date with any changes and the special needs off each individual. 2. I am about to start my NVQ3 which will help to give me more knowledge on all aspects of the job. Four thought they met regularly with management for support and one usually. All five knew what to do if a complaint was made. One said, “I would go to the manager or senior staff on duty”. Four thought information was always passed on between staff and one usually. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 7 Four thought there was always enough staff to meet the needs of residents and one usually. Two commented, 1. All staff work well together and are very good at covering shifts. Service users needs are met. This is paramount to how the home is run. 2. Always well staffed. Four thought they had the right support to meet the diverse needs of residents and one usually. One said, “We have ongoing in-house training that is proving very effective”. Four staff members commented on what the home does well. 1. We look after and respect the needs of the service user both legally and morally. 2. Everything is done very well. 3. The needs and well-being of service users are always the main priority. 4. We meet the needs of all our residents. Two commented on what the service could do better. 1. There is always room for improvement in everything. I personally feel that this company is aiming to make sure that everything is run professionally and service users are the number one priority. 2. Things are improving each day. One further comment from a staff member said, “The manager is very good at managing the home as well as seeing to the needs of residents and staff”. In general the very positive comments showed staff were enthusiastic about the care home and felt supported to perform their roles. What the service does well: One visitor said, “The home is very good. The staff cannot do enough for the residents and they are all very friendly. They give good care. I am very satisfied with what they do”. Staff spoken to on the day of the inspection were aware of the needs of the residents they looked after and this was reflected in the general satisfaction of relatives with the service offered. One visitor said, “You can come and visit when you want”. Staff were observed to have a pleasant relationship and offer refreshment to visitors. Visiting was unrestricted to enable residents to meet their families and friends as a social occasion. Paperwork supplied and information gained prior to admission ensured residents and their families were suitably placed. Plans of care were developed with the aid of families and residents to provide staff with sufficient knowledge to help meet the needs of residents accommodated at the care service. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 8 Residents had access to specialists to ensure their health care needs were met. Privacy, dignity and as much independence as possible were viewed as important and helped maximise residents contentment. Although a relatively new service the manager was aware of the need to provide leisure activities that would help residents live a fulfilling life. Staff members said, “I love it here working with the residents and I like working with the staff. I feel well supported. I think it is a good company to work for. I feel I am sufficiently well trained and helped to do the work. I learn something new every day” and “ I like working here and feel supported. It’s a good team. I have not got any complaints”. The supportive and open management allowed staff to feel valued as a team member. No complaints had been made to the Commission for Social Care Inspection since opening. Staff questioned were aware of how to complain. The accessible complaints procedure allowed residents and their families to voice their concerns. No adult abuse issues had been raised since the care home opened. Policies, procedures and staff training provided a framework to safeguard vulnerable adults. The care home was warm, clean, tidy and free from offensive odours. The suitable equipment was domestic in character and helped provide a homely atmosphere. Food served at the home was tasteful and met residents nutritional needs. Residents who were able to comment said they were happy or well and were satisfied with the care they received. Health and safety policies, procedures and maintenance of equipment helped protect the welfare of residents and staff. What has improved since the last inspection? This is the first time the care home has been inspected. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 9 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. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 10 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 Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 11 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): OP1 – OP6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation, such as the statement of purpose, contract and service user guide enabled residents to make an informed choice to enter the care home. The thorough assessment process ensured staff had sufficient information to be able to meet the needs of residents. Prospective residents were offered a trial visit to allow them to decide if they liked the home. EVIDENCE: The care service did not provide intermediate care. There was a statement of purpose and service user guide, which told residents and their families what they could expect if they stayed at the care home. This was supplemented by explaining the terms and conditions of residency. Residents and their families were aware of what was on offer and planned their admission using the paperwork given. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 12 Three residents were involved in the case tracking process. Social services or the local Primary Care Trust had provided assessment documentation. A suitable staff member completed an assessment of each individual. The documentation of the three residents case tracked was up to date and fully completed. When the assessment had been completed residents were informed their needs could be met at Sandybrook House. Each residents needs were assessed prior to admission and staff were able to develop plans of care from the information gained. The manager said, “When families come for a look around I would ask them what kind of room they would like and explain the process of admission. Show the menu choices. Residents and their families can have a look round. They don’t need to make an appointment so they can take us as they see us. They can come in as day release, have a meal, or have an overnight stay. We would show them the activities on offer. They would be introduced to staff and residents. We give everyone our brochure which tells them all they need to know”. Residents were offered a test drive of the care home to see if it met their needs. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 13 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): OP7 – OP11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care had been developed and reviewed to ensure staff were up to date with each residents needs. Residents had access to specialists to meet their health care needs. Policies, procedures and safe administration of medication protected the health and welfare of residents. Residents were treated with respect and dignity to ensure they were comfortable with the personal care they received. EVIDENCE: Three residents were involved in the case tracking process. This involved examining the plans of care, talking to residents where possible and discussing care issues with two staff members. Care was delivered by staff, written accurately in the plans and met the expectations of residents. Plans of care had been developed with residents or their families. Plans of care had been reviewed on a monthly basis. A record of a resident’s last wishes was contained within the plans of care. Plans of care enabled staff to care for the holistic needs of residents. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 14 Each resident case tracked had their needs risk assessed. This included an assessment for pressure area care, nutritional needs and moving and handling needs, including a falls risk assessment. Equipment was provided for residents where a risk was demonstrated such as pressure relieving mattresses or frames and wheelchairs. Outpatient and other appointments were recorded within the plans of care. Residents had access to specialists to receive up to date care or advice. Policies and procedures for the administration of medication had been reviewed in line with the Royal Pharmaceutical Societies guidelines. Medication records were up to date and contained no unexplained gaps. Staff had access to current medication publications and their local pharmacist to gain advice. The registered manager said, “ We have a good relationship with the pharmacist who has audited the system we use. Gave us advice to get things right”. There was a safe system for the ordering, administration and disposal of medication. There was a Controlled Drug register and appropriate cupboard. There was a fridge for the storage of medication. The temperature of the fridge was recorded. There was a signature list for all staff who administered medicine. The safe administration of medication helped protect the health and welfare of residents. Residents were observed to be treated with privacy and dignity. Staff spoken to were aware of privacy and dignity issues. All doors had a lockable facility and staff were instructed to keep doors closed when giving personal care. Staff sign a policy and procedure book, which details confidentiality, privacy and dignity. During the case tracking process staff described the way they encouraged some independence for the benefit of residents. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 15 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): OP12 – OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure activities provided were suitable to resident’s tastes and helped provide a fulfilling life. Visiting was open and unrestrictive to encourage socialising with family and friends. Residents were able to exercise choice to retain some independent living. The food served at the home met residents nutritional needs. EVIDENCE: The manager described choices residents could make such as, “Choice of routine would still be allowed if someone did not want to get up. Residents are able to stay in their rooms or go back upon their beds”. Staff described the choices they offered residents when they were assisting with personal care such as what they wore. Choices were offered at mealtimes and within the daily routine of the home for residents to feel they retained some control of their lives. Meals provided were hot, nutritious and tasteful. Residents who required assistance were observed to be fed in a discreet and individual manner. There was a choice of meal. Resident’s dietary preferences were taken on admission and the information was passed to the cook. The cook carried out necessary environmental health checks. There were sufficient dining facilities for all Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 16 residents to enjoy a meal as a social occasion. Special diets were catered for. The food served at the home was suitable to resident’s tastes. Visiting was unrestricted and allowed residents social contact with family and friends. The manager said leisure activities were offered but she was gaining the preferences of residents to develop a more formal system. When more residents have been admitted a bigger cross section of ideas will drive what is offered. Leisure activities helped provide a stimulating atmosphere for residents. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 17 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): OP17 – OP19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents or their families were aware of their right to complain and confident to approach management with any concerns. Robust policies, procedures and staff training protected residents from possible abuse. Residents were able to access the legal system to preserve their rights. EVIDENCE: The complaints procedure was easily accessible, met current timescales and gave residents the option to contact the CSCI. There have not been any complaints made to the CSCI but one complaint made to the service was dealt with satisfactorily. The registered manager said, “We will allow postal votes or people may vote by proxy. If people have the capacity to vote they are escorted to the polling station. Some residents have a solicitor who deals with finances and a family member has power of attorney. There is an advocacy service, the East Lancashire advocacy service we could use for residents who have no family”. Resident’s rights were protected at the care service. There was a copy of the ‘No Secrets’ document. The registered manager said they would use the Blackburn with Darwen adult abuse procedures to follow local guidance. There was a whistle blowing policy. Both staff spoken to were Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 18 aware of the policy. There have not been any incidents of abuse since the home opened. All staff had been trained in the protection of vulnerable adults. Policies, procedures and staff training helped protect residents from possible abuse. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 19 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): OP19 – OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a clean, tidy and safe environment. Fixtures, fittings and furnishings were domestic in character and provided a homely atmosphere. The services and facilities provided a comfortable setting and met resident’s environmental needs. EVIDENCE: A tour of the building conducted on day one of the inspection. The home was observed to be warm, clean and tidy with no offensive odours. All areas of the home remain well decorated. There was a plan of routine maintenance and two men were there on the day of the inspection. One fixing door closures and one tidying up outside. The outside space is secluded and safe but it was not particularly inspiring for residents with dementia. Communal space was modern and suitable to the needs of residents. There was a music lounge and general lounge. In one lounge and the dining room Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 20 there was a large television. Around the home there were several furnished areas for residents to sit. The dining room was open to residents and had more seating than residents would need. Outdoor space was accessible. Lighting was domestic in character and sufficient for residents to be able to read or attend leisure activities. There were good areas of natural lighting. Furnishings were new and met residents needs. Baths and a shower were assisted and many bedrooms had bathing or shower facilities. Toilets were near to communal areas. All rooms had an en-suite toilet. Some rooms were larger and offered more facilities. Disability equipment was sited in key areas to assist residents maintain independence. There was a good level of equipment observed in each room. Sensible lighting meant the use of moveable lamps were not needed allowing residents to read in bed should they wish. Doors were lockable, windows were restricted and radiators guarded. However, on testing the water supply one sink tested was much too hot. All rooms were carpeted or had laminate flooring. Each room had a lockable space. Rooms had been personalised to resident’s tastes. All rooms had natural lighting. Rooms were centrally heated. Emergency lighting was provided and maintained throughout the home. The laundry is sited well away from food preparation areas and walls and floor can easily be cleaned. There were washing and drying facilities with machines that reach current specifications. Staff were issued with booklets for infection control and the manager had a copy of the Lancashire Primary Care Trusts infection control booklet for staff to follow. Infection control policies, procedures and staff training helped protect the health and welfare of staff and residents. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 21 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): OP27 – OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures protected residents from possible abuse. Resident’s needs were met by the numbers and skill mix of a well-trained staff group. Induction and foundation training was undertaken in a professional manner to ensure staff are competent to meet the needs of residents. EVIDENCE: Two staff files were examined during the inspection. All necessary documentation and checks had been obtained for the employment of staff to help protect the health and welfare of residents. The staffing rota demonstrated sufficient numbers of well-trained staff were on duty throughout the day. The manager was planning to increase staff as residency levels increased in a controlled manner. Staff received training in many aspects of caring for the resident group accommodated at the home. Over 50 of staff had attained NVQ qualifications. Supervision was being carried out monthly. Completed induction and foundation training was observed in staff files. Staff questioned said they were receiving good training. Relatives were satisfied that residents’ needs were met by staff employed at the home. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 22 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): OP31 – OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefited from the open and transparent leadership of management. Quality assurance systems allowed management to react to the views of residents, staff and stakeholders. Proven financial systems safeguarded resident’s monies. Policies, procedures and staff training helped protect the health and safety of staff and residents. EVIDENCE: The manager said, “I have 5 years experience working in a care home with three years as a senior member of staff. I have got NVQ 2 and 3 and completing NVQ4. Prime Life are putting me on the RMA course. I am enjoying the job and I feel well supported by everyone in the organisation”. The manager was aware of the need to register with the Commission for Social Care Inspection to meet current standards. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 23 The manager demonstrated that the financial system used to protect resident’s monies was safe. Quality assurance systems had begun to be developed. There were regular staff and resident/family meetings. Some surveys had been conducted, mainly around food preferences. The manager was aware of the need to implement quality assurance systems when more residents are accommodated at the home to allow management to react to the needs of residents. There were health and safety policies and procedures. Health and safety legislation was available at the home for staff to access. Staff were trained in health and safety, fire awareness, first aid, moving and handling, food hygiene and infection control. All electrical and gas appliances and installation had been maintained. Fire tests and drills had been carried out. Accidents were recorded. Health and safety policies, procedures and staff training helped protect the health and welfare of staff and residents. All records inspected were up to date, accurate and stored safely to preserve confidentiality. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 24 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 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 2 3 3 3 3 3 Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP8 OP19 OP25 OP31 OP33 Good Practice Recommendations The manager should contact the tissue viability service for advice and pressure relief planning. The registered person should look at ways of making the garden area attractive to residents. The registered person should ensure water delivery temperatures are safe for residents. The registered person should ensure the current manager attains the necessary qualifications and is registered with the CSCI The registered person should ensure quality assurance systems are developed fully when the homes occupancy is increased. Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston, PR2 2YQ 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 Sandybrook House DS0000071197.V356761.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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