Inspection on 06/10/06 for Sandylane Hotel

This inspection was carried out on 6th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Sandylane Hotel 02/08/05

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Sandylane Hotel 33 Sands Lane Bridlington East Yorkshire YO15 2JG Lead Inspector MrTom Tomlinson Key Unannounced Inspection 09:30 6th October 2006 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 Sandylane Hotel DS0000064418.V310872.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. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandylane Hotel Address 33 Sands Lane Bridlington East Yorkshire YO15 2JG 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) 01262 403037 01262 403067 Sandylane Ltd Mrs Judith Ann Dennis Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Sandy lane Hotel is an adapted, purpose built care home on Sands Lane, Bridlington, with sea views. It is a four-storey building which once belonged to the Local Authority, but which is now owned by Sandylane Limited. Service users are located on the ground, first and second floors, whilst offices for administration are on the third floor. A passenger lift goes to all floors. There are twenty-five single rooms with ensuite toilet and three shared rooms with ensuite toilet. The home has three bathrooms, two showers, eight separate WCs, together with three lounges and two dining rooms. The home cares for service users who are elderly and may have dementia and offers personal care, emotional support and a level of entertainment and activity. The home tries to encourage relatives and friends to become involved in activities of service users outside the home. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection formed an integral part of the annual ‘key inspection’ process for the home undertaken by the Commission for Social Care Inspection (C.S.C.I.). Information contained in this report was obtained through discussions with the home’s registered manager, the staff on duty at the time of the visit, seven service users and the relatives of two service users. A discussion was also held with a visiting District Nurse and a Social Worker. The report also reflects comments made in three Comment Cards returned from health and social care professionals and the information provided by the registered manager in the pre-inspection questionnaire. In addition the report includes relevant information obtained by the C.S.C.I. prior to, and subsequent to, the inspection visit. A number of statutory records kept by the home were also examined. What the service does well: What has improved since the last inspection? The registered manager has continued to review, and amend, the home’s policies, procedures, records and practices to ensure that they remain meaningful and relevant. Lines of communication between staff and service users have been improved. Since the previous inspection greater emphasis has been placed on providing the service users with a greater degree of choice Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 6 of social activities both within and external of the home. Positive action continues to be taken to ensure that the views of the service users regarding the quality of the service provided are actively sought. This is particularly relevant with regard to the meals where the service users are provided with genuine choice and their preferences taken into account. The staff continue to be provided with opportunities to participate in a range of training courses and since the previous inspection visit, several have obtained a National Vocational Qualification. The staff recruitment process has been reviewed to ensure that it incorporates a robust vetting procedure. In summary, the registered manager is not complacent but continues to look at ways of improving the standard of the service provided and consequently the quality of life experienced by the service users. 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. Sandylane Hotel DS0000064418.V310872.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 Sandylane Hotel DS0000064418.V310872.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, 3, 4, 5 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with a range of information so that they can make a considered decision as to whether they wish to live in the home. EVIDENCE: In addition to providing prospective service users with a copy of the Service Users’ Guide and a brochure of the home, every service user was provided with an ‘information pack’ in their rooms. This contained additional information to that contained in the Service Users’ Guide and consequently ensured that all new service users were fully aware of the service and facilities provided by the home. A service user confirmed this. Three service users’ care records were examined. They contained recorded evidence that all prospective service users were fully assessed prior to their admission into the home. This was in addition to any assessment provided by a placing authority. The home’s assessments were reasonably detailed, identified a prospective service user’s needs, abilities, likes and dislikes and provided a sound base on Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 9 which their initial care plan could be developed by the home. According to the registered manager the assessments were, where practical, undertaken in the prospective service user’s own accommodation. They, and their relatives, were also encouraged to visit the home so that they could make a considered decision as to whether the home was suitable. A member of staff confirmed this. The registered manager demonstrated a good understanding for the need for a comprehensive assessment to ensure that a proposed placement is appropriate and that the home had the capacity, and the staff expertise, to meet the needs of a prospective service user. Intermediate care is not currently provided by the home. Sandylane Hotel DS0000064418.V310872.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 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users’ personal and health care needs are met through excellent support from the staff and good levels of input from health and social care professionals. EVIDENCE: All of the service users had been provided with a care plan by the home. These care plans were based on, and were in addition to, any care plan provided by a placing authority. The care plans were comprehensive and covered all elements of care. They were tailored to the assessed needs of the individual service user. The records provided confirmation that the service users had agreed to their care plans and had been involved in any changes that were necessary. This provided the service users with a degree of ownership and control over the provision of care they required. Where service users had been assessed as not being able to fully understand their care plans, the agreement of their relatives or representative had been sought. Two visiting relatives confirmed that they were aware of the respective service Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 11 user’s care plan. The records confirmed that the care plans had been regularly reviewed and amended as necessary thereby ensuring that the plans remained relevant and meaningful. The home operated a ‘key worker’ system of care staff and these staff had direct input into the development of the care plans. The staff demonstrated an excellent understanding of the service users’ needs. They were very aware of the need to promote the service users independence and they provided examples of this. The staff spoken to also emphasised the need to maintain the service users’ dignity and privacy. All the bedrooms were currently being used for single occupancy and had en suite facilities. This ensured that personal care was provided for the service users in the privacy of their rooms. It was noted that the staff spoke to the service users in a friendly but respectful manner. It was evident that the staff and service users had a genuine affection for each other. One visitor commented, “What they (staff) do here that they don’t do in other homes is love people (service users). This home is exceptional, they know about the person – they are not just clients or residents”. The records indicated that the service users health care needs had been readily and appropriately addressed with a good level of input from health and social care professionals. A visiting District Nurse stated, “The staff are very caring. They (service users) are well looked after. There is good cooperation and the staff take my advice. I look forward to coming here each day. I think that this is one of the best homes”. A visiting social worker commented, “I think that I can best put it this way – this is one home where I would happily let my mother live – the residents are very well cared for”. On the day of the inspection visit it was observed that the service users were dressed and groomed to a high standard. The majority of the female service users, for example, were wearing makeup and jewellery. The nutritional needs of the service users had been monitored and the catering manager provided evidence of this. The records confirmed that the service users had been regularly weighed and that any dramatic change in weight had been investigated and, where necessary, referred to the health services. Only those service users who were weight bearing could be weighed on the type of scales used by the home. Reliance was therefore placed on the use of observation of those service users who could not be weighed due to their frailty. From discussions with the staff it was apparent that they were aware of the possibility of the less mobile service users developing pressure sores and records had been maintained of pressure sore risk assessments. According to the home’s records, none of the service users had pressure sores at the time of the inspection visit. All of the service users had been registered with local medical practices, which, according to the registered manager, provided good standards of support. The home had a dedicated medication/treatment room that was kept locked when not in use. The ‘in-use’ medication was secured in two dedicated drugs trolleys that were also fastened to the wall when not in use. The responsible member of staff carried the keys to the medication facilities. The medication records were complete and up to date. The member of staff responsible for the medication procedures described the process that involved administering medication both from a Monitored Dosage System and from original containers. It was evident that it balanced efficiency with safety Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 12 and ensured that the possibility of an error had been minimised. Facilities were in place for the administration of controlled drugs although none were in use at the time of the inspection visit. The records confirmed that those staff responsible for the administration of medication had received appropriate training that included the safe handling of medication. From discussions with the manager, staff and relatives of service users, it was evident that considerable emphasis was placed on the care of service users who were in the final stages of their life. Service users who were dying were, for example, never left alone and were provided with excellent emotional as well as physical support. Several examples were provided of this approach. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are provided with the opportunity to participate in a range of social activities thereby providing them with stimulation and minimising the possibility of boredom. They are also provided with a choice of wholesome and nutritious meals that take into account their personal preferences. EVIDENCE: A programme of social activities had been developed by the home. The needs, wishes and abilities of the service users had been taken into account. These had been recorded in the relevant care plans. It was evident that some of these activities included external entertainers and group activities that provided stimulation for the service users and maintained their dexterity and physical fitness. The manager had endeavoured to provide group trips out but with only limited success as many of the service users were reluctant to go very far. The records provided evidence that the care staff, in particular the key workers, were expected to spend ‘quality time’ on a one-to-one basis with their allocated service users. This ‘personal time’ could be spent either simply in having private discussions with a service user or taking them out. The manager said that priority for going out had to be given to the more frail Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 14 service users and those who had few, if any, visitors. From discussions with the service users it was evident that boredom was not an issue. They were also aware of what social activities had been arranged for that day, who was providing it and at what time. This had been achieved both through word of mouth and through the provision of a weekly information sheet. It was evident from discussions with service users that they could decide whether or not they wished to participate in the activities. One male service user said that he preferred to stay in room and that the staff had respected this. The service users also confirmed that they could purchase newspapers and magazines of their choice. It was evident during the inspection visit that a steady stream of visitors came and went from the home. It was observed that they were welcomed by the staff and were able to see the respective service user in private if they wished. Those visitors spoken to were very complimentary regarding the service provided by the home and in particular the support provided by the manager and the staff. From the information provided by the Catering Manger, it was evident that the service users were provided with varied diet that took into account their personal preferences whenever possible. This had been achieved through the use of regular written surveys of the service users’ that enabled them to make their views known on the quality and choice of meals. It was also apparent that action had been taken in response to these surveys. It was evident that the catering staff had excellent knowledge of the service users’ food preferences and of any specific dietary needs. They catering staff had endeavoured to make ‘liquidised meals’ more appetising by separating out each dish. They had good contact with the service users and it was observed that during lunch the catering staff actively sought the views of the service users regarding the meal. Lunch was the main meal of the day and was served in the dining room in two sittings. This arrangement had been introduced to take into account the needs of the service users and the level of input required from the staff. Lunchtime was an unhurried social occasion with service users sitting in a maximum of four at well laid out tables. A menu sheet was on each table so that the service users were aware of what was available for each meal. There was a genuine choice of meal. Staff had sought the service users’ preference earlier in the day. The meals were delivered straight from the kitchen to the dining room in a ‘dumb waiter’. This ensured that the meals were reasonably hot when served by the staff. The staff served the meals in friendly, patient and respectful manner. It was also observed that the service users could make adjustments to the meal ordered thereby taking into account individual tastes and ‘changes of mind’. Those service users spoken to commended the quality of the meals. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The internal and external support provided for the service users should ensure that any issue or concern is quickly identified and acted upon thereby ensuring their safety. EVIDENCE: All of the service users and their visitors had access to the home’s complaints procedure, as it was included in the information pack that was available in each room. It was evident from discussions with the manager that all complaints, regardless of importance, were taken seriously and were fully investigated. It was also apparent that the manager had developed an environment in which the service users and visitors could be open about their views and concerns without any fear of retribution. A service user who, when referring to the manager, said, “She’s got a good heart – she listens to you” confirmed this. Those visitors and service users spoken to could not envisage making a formal complaint but said that they would not hesitate to discuss any concerns with the manager or staff. All of the staff, regardless of role, had received training in Adult Protection procedures. They demonstrated a good understanding of the types and indications of abuse and of the action to take in the event of an allegation of abuse being made. It was apparent that a good level of internal and external support had been established for the service users and consequently any concern should be quickly identified and acted upon. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are provided with a comfortable and pleasant environment in which they can live their lives at their own pace thereby enhancing their quality of life. EVIDENCE: Sandylane was originally purpose built for the local authority. It is a detached property built on four floors and is located close to Bridlington’s south bay. It has private gardens that are accessible to the service users including those with mobility problems. The care home has its own car parking facilities and there is unrestricted on-road parking. A passenger lift and stairs provide access to the upper floor. For purposes of security the home has CCTV to monitor the outside of the property. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 17 All of the service users bedrooms had en suite facilities, which enhanced the service users’ privacy and dignity. Whilst the home had three double bedrooms, at the time of the inspection visit these were being used for single occupancy. The registered manager stated that service users would only share at Sandylane if both occupants of a bedroom had clearly agreed to do so. Those bedrooms inspected were decorated, furnished and maintained to a good standard. It was evident that the service users had been encouraged to furnish their rooms with their personal belongings thereby personalising their rooms. On each of the bedroom doors there were clear signs that provided the name of the occupant and the name of that person’s key worker. These signs were individualised to assist those service users with dementia in locating their room. There were adequate toilets, baths and showers that took into account the physical needs of the service users. The home had three small lounges as well as dedicated ‘sitting areas’. This provided the service users with choice of where, and with whom, they wished to spend their time. The lounges were furnished to a high standard. A television and a range of books, magazines and board games were available in each lounge. Also in the lounge and sitting areas were fish tanks, birdcages and in one area a cage for several chipmunks. These were all maintained in a clean and hygienic condition. The intention for this was, according to the manager, to provide additional stimulation for the service users. The home had two dining rooms one of which was dedicated for use by those service users who required staff support with eating. The home also had a non profit-making shop from which the service users could purchase toiletries, snacks and stationary. On the day of the inspection visit the home was very clean and totally free of any offensive odours. Those service users spoken to confirmed that this standard of cleanliness was the norm. One stated that it was this that had influenced them to live in the home. The home’s records confirmed that the home satisfied the requirements of the Fire and Environmental Health Departments. Those service users with advanced dementia were accommodated on the first floor but had access to all of the floors by use of the passenger lift. Risk assessments had been undertaken, however, that indicated that some of the service users could be at risk from using the stairs. In order to overcome this problem, and with the approval of the fire department, ‘multi-handled’ doors had been fitted to the entrance to the stairs on the upper floors. Thereby limiting access to the stairs by the more vulnerable service users. An emergency call point was tested in a lounge on the upper floors. A member of staff promptly responded to this. The service users confirmed that the staff always responded to emergency calls regardless of the time during the day and night. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are provided with excellent support and care from an enthusiastic and competent staff team that ensures that they are provided with a good quality of life. EVIDENCE: A staff roster was provided for the Commission of Social Care Inspection prior to the inspection visit. This indicated that there was adequate care staff available both during the day and night to meet the needs of the current service users. The service users confirmed this. Several said that the staff were always readily available and would always respond to a call-bell. There were also adequate numbers of ancillary staff and the manager confirmed that she or the deputy manager were always on-call outside of normal working hours. It was evident from discussions with the staff, regardless of role, that they had an excellent understanding of the service users’ needs. It was also apparent that they had established a close but professional relationship with the service users. The staff involved the service users, for example, in their home lives by telling them what they had done during their time off. On the day of the inspection visit a member of care staff brought in her newly borne baby for the service users to see. Through this approach the staff endeavoured to keep the service users in touch with life outside of the home. Without exception, all of the service users and their relatives spoken to Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 19 commended the efforts of the staff to provide a pleasant and supportive environment. The staff records confirmed that the staff, regardless of role, had been given the opportunity to participate in a range of courses on statutory and professional subjects. These included topics such as dementia, drug (medication) awareness, infection control, challenging behaviour and aggression management. New staff were required to undergo a comprehensive induction and foundation training course leading to a National Vocational Qualification (NVQ). Over 66 of the staff had achieved a NVQ and several others were in the process of obtaining it. The staff spoken to confirmed this good standard of training and also that they received personal supervision and appraisal on a regular basis. Without exception the staff commended the support they received from the manager both on a professional and personal basis. Staff meetings, for all sections of the staff, were held on a regular basis. Minutes had been kept of these meetings. The staff confirmed that they were able to fully participate in these meetings and had the opportunity to submit agenda items. All staff were encouraged to attend these meetings and those ‘off-duty’ at the time of the meeting received payment for attendance. The home had an appropriate staff recruitment and selection process that included reasonably robust vetting procedures. The staff records examined confirmed this. The excellent level of training and support provided for the staff had culminated in a stable, cohesive, knowledgeable and enthusiastic staff team that held common aims and saw the welfare and quality of life of the service users as being of the utmost importance. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An experienced and qualified manager provides the staff and service users with excellent levels of support to ensure that the assessed needs of the service users are met. EVIDENCE: The registered manager has had considerable experience in care management. She is appropriately qualified having obtained a National Vocation Qualification at level 4 in care and the Registered Manager’s Award. These are in addition to other relevant qualifications she has achieved. During the inspection visit the manager demonstrated a good understanding of the needs of the service users and the importance of promoting their independence and choice. She provided numerous examples of this. From discussions with the staff, service Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 21 users and their relatives, it was apparent that they have considerable respect for the manager and held her in high esteem. It was apparent during the inspection visit and from the discussions that the registered manager’s caring, enthusiastic and happy personality was reflected in the running of the home. Referring to the manager a visiting healthcare professional commented, “She’s always on the ball” and a service user said, “She’s got a good heart – she will always listen to you”. It was evident that the manager had clear aims as to the quality of care she wanted for the service users and it was evident from discussions with the staff that they too had the same aims. The registered manager was always accessible to service users and gave them priority over anything else. This was evident from the way that service users sought her out and asked her advice during the inspection visit. The manager had delegated appropriate responsibilities to staff and had taken positive steps to involve them and the service users in the daily routines of the home. The care home had a comprehensive quality assurance procedure that included actively seeking the views of the service users and visitors as to the quality of the service provided. There was clear evidence that the home’s policies, procedures and practices had been regularly audited and updated as necessary. The registered manager demonstrated a positive attitude towards change and the need to constantly challenge the quality of the service provided. The home had a business plan available and had achieved the Investors in People Award. The records indicated that where possible the manager had encouraged service users or their families to retain control of a service user’s personal money. Where this was not possible arrangements were in place to ensure the safe keeping of service users money including the maintenance of individual financial records that clearly showed any transactions made on behalf of a service user. From discussions with the staff and an examination of several staff records, it was evident that the staff were provided with regular supervision and appraisal. The staff said that they found it to be a positive process that was designed primarily for their benefit. From an examination of the records, including the pre-inspection questionnaire, and an inspection of the premises, it was evident that the manager had taken appropriate action to ensure a safe environment for staff and service users. This included the development and implementation of risk assessments. The hot water outlets were checked at two points and both registered as being within the recommended maximum temperature. The staff records indicated that all staff had been provided with training, regardless of role, in health and safety related subjects. As far as could be ascertained from the records and correspondence, the home satisfied the specific requirements of the Environmental Health and Fire Departments. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 22 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 4 X 4 4 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 3 3 3 4 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 X 3 Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 23 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. Refer to Standard OP8 Good Practice Recommendations Consideration should be given to providing facilities and equipment to enable the more frail service users to be weighed on a regular basis. The Registered Manger should discuss this issue with the Healthcare services. Sandylane Hotel DS0000064418.V310872.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Sandylane Hotel DS0000064418.V310872.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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