Inspection on 18/10/05 for Sanford House Nursing Home

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sanford House Nursing Home 08/05/07

Sanford House Nursing Home 08/05/06

Sanford House Nursing Home 20/05/05

Sanford House Nursing Home 19/10/04

Sanford House Nursing Home 26/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Sanford House Nursing Home Danesfort Drive Swanton Road East Dereham NR19 2HH Lead Inspector Judith Huggins Announced 18 October 2005, 09:30 th 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 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. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sanford House Nursing Home Address Danesfort Drive, Swanton Road, East Dereham, Norfolk. NR19 2HH. 01362 690790 01362 690890 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sanford House Limited Mrs Susan Lancaster Care Home 43 Category(ies) of Dementia - over 65 years of age (42), registration, with number Old age, not falling within any other category of places (42), Physical disability (1) Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home will only receive patients who are not liable to be detained under the Mental Health Act 1983. 2. The Home may accommodate one (1) male person with a physical disability, named in the Commissions records, who is under 65 years of age. 3. The Home may accommodate up to forty-two (42) elderly people over the age of 65 years, of either sex, who may or may not have dementia. 4. Maximum number not to exceed forty-three (43). Date of last inspection 20th May 2005 Brief Description of the Service: This home provides care with nursing to a maximum of 43 elderly people. It is located on a private driveway close to the centre of the market town of East Dereham. The building is divided into two units with the Carrick unit caring for older people and one person with physical disabilities, and the Shannon unit caring for older people with dementia. There is a secure courtyard garden at the centre of the home, with access from some bedrooms. There are small shrubs and flower borders, and some small lawn areas. Garden seats and tables are provided. It was purpose built in 1998 and all accommodation is located on the ground floor. Wheelchair access and the car park are located at the front of the home. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over nine and a half hours and was announced. During the course of the inspection, a brief tour of the premises was made, and a sample of records including care plans was checked. Five relatives were seen on their own, and a further four were spoken to in the company of residents. Four residents; four care staff, one member of catering staff, the manager and regional manager were spoken to. Comment cards were received from one resident, thirteen relatives and two visiting health professionals. Two letters from relatives were also received, and where appropriate the views expressed have been included in the report. Four care plans and selections of other records were inspected. What the service does well: What has improved since the last inspection? Relatives identified the manager as someone to whom they could take their complaints, and several commented that their worries were addressed properly. (See also below.) There has been a welcome improvement in setting out of care needs and frequency with which these needs are reviewed. (See also below.) Efforts have been made to increase the recreational and social activities available (although there is room for further improvement in this area). Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 6 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. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 standard(s) 6 The standard is not applicable. EVIDENCE: Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 9 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 standard(s) 7, 8 and 10 There is continuing improvement in the way the health, personal and social care needs are set out, although records do not yet support that needs are fully met. Residents feel that their right to privacy and respect is upheld, although evidence from one set of relatives indicated this might on occasions be compromised. Standard 9, regarding the management of medication, has been inspected separately by the Commission’s specialist pharmacist inspector. EVIDENCE: Care plans seen set out a range of need and in most cases, and are clear about the actions required of staff to fulfil these needs. However, there is a lack of detail on some, for example about the frequency of residents’ needs (or wishes) for baths and showers, or how often chiropody treatment is needed. There are inconsistencies in assessments, one giving the wrong “score” when added up, and others describing people as both “immobile” and using an “aid”, which is contradictory. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 10 A member of the care team commented that there are sometimes conflicting instructions from senior staff as to how people should be moved and handled, indicating “moving and handling care plans” are not consistently followed. Personal care records do not support that personal care needs are being met. For example, one person with continence problems had only one shower/bath recorded for the last 18 days. Feedback from four relatives does not support that continence is promoted relatives and some staff confirming that call bells were not always attended to promptly. Two relatives said that the resident they visited had complained to them that, following a call for assistance at night, she was told to “do it in the bed”. This had upset the resident concerned. See also complaints and protection section and staffing standards. Dates show that assessments and care plans are reviewed more frequently than noted at previous inspections, this is to be commended. However, residents and/or their representatives are not involved in review. One resident did not know what a care plan was and none of the five relatives asked could confirm that they were involved in planning care. However, almost 62 of relatives completing comment cards say that they are kept informed of important matters. The assessment tool in use to identify risks from unintentional weight loss gives clear instructions to follow when changes occur, this is to be commended. One person’s indicated the need for intake monitoring for three days and monthly review. However, this was not reviewed again until three months later. It is noted that the necessary referral to a dietician has now been made. The latter is good practice. Two relatives expressed concern that staff do not always report and record health related issues properly, or else do not refer to records. Two examples were given, one of a bruise for which staff had no explanation, and one of a dressing, which relatives say had been in place for two weeks and which they believed to have been unchanged. They say the nurse to whom they reported this told them she did not know that the resident had a dressing on. Staff were asked about the numbers of residents with MRSA and the numbers of people with pressure sores. Different answers were given, raising concerns about consistent awareness of health care needs. Almost 62 of relatives responding on comment cards are satisfied with overall care. The remainder are not. Two visiting health professionals completing comment cards say that they are satisfied with the overall care provided to residents and that staff demonstrate a clear understanding of care needs. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 11 Residents spoken to say that their privacy is respected. However, feedback from one set of relatives was that a staff member was seen emerging from a bedroom carrying a wet continence pad which dripped on the carpet on the way to disposal, not having been placed discreetly in a bag beforehand. One relative confirmed that handovers took place as they had “heard it”. A letter from one relative indicated they were not confident mail was always delivered directly to residents unopened, although the management team state they are confident this is not opened. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14 and 15 There have been some improvements in attempting to meet the social needs of residents. Residents are able to maintain contact with family and friends and feel that they are given choice although some limitations were noted. There are some shortfalls in the provision of a balanced diet although choice is available. EVIDENCE: There was information about activities posted in various locations, and a forthcoming firework party is planned with invitations extended to relatives. However, care notes do not support that residents participate in regular activities. Residents and relatives commented that staff do not often get time to spend with them attending to “niceties” such as manicuring nails. Staff confirmed that, particularly in the Carrick Unit, they are very busy and could not often spend 1:1 time with residents other than when assisting with personal care. However, one staff member said that there was adequate time to spend on activities during part of the afternoon in the dementia care unit (Shannon unit). Relatives of those who are frail or with limited mobility, felt that Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 13 activities were not available. One person responding in writing said that there was a lack of stimulation, interest and variety. Some effort has been made to secure input from an activities coordinator in another of the homes owned by the provider, but there is currently no-one with responsibility for this working at the home. The manager is aware of shortfalls in this area. Relatives were noted as visiting throughout the course of the inspection day. Nine people (69 ) confirmed that they feel welcome at the home at any time, although three relatives completing comment cards (just over 23 ) say they do not. One person did not respond to the question. Some residents were in contact by telephone. All of the relatives say that they can visit in private. Residents confirm that they have a choice of food at mealtimes. Rooms seen show that residents are able to bring in items from home to help to personalise their bedrooms. One person said that they had preferred to spend time in their room when first admitted to the home, but was now happier in the main lounge and that staff helped with getting her there. There are sometimes difficulties upholding individual choices and preferences, such as the time for going to bed in the evening, due to conflicting demands and pressures on staff time. One substantiated complaint recorded showed this was concerning the person’s need for assistance at their preferred time. It is acknowledged that there would be difficulties if all residents chose to rise or retire at the same time. There are two separate dining areas, one in each “unit” of the home. Some residents eat in their rooms. Residents spoken to say that there is a good variety of food but one commented that sometimes sandwiches are too thick. The range of choices shown on menus provided has increased and this is a welcome improvement. The mealtime routine did not appear to be rushed, although it was noted that one person in the dementia care unit with a pureed main meal was attempting to eat this alone with fingers. No staff member was present and assisting at the time. Comment has been made elsewhere about the process of assessment of nutritional risk. Both of these issues compromise the ability to deliver a balanced diet. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Relatives are not always confident that their concerns will be acted upon and do not always feel comfortable in raising concerns on behalf of residents. There are measures in place to protect residents from abuse, although this is compromised. EVIDENCE: Records of complaints have improved and now show more clearly whether concerns have been substantiated or not. Relatives say that when they make complaints to the manager these are addressed. Further discussion indicated that sometimes issues were raised as “concerns” rather than complaints and were not taken up. Concern was also expressed by four relatives that complaints might “come back” on residents. Two relatives indicated in writing that if they complained this had sometimes caused trouble. Two said that sometimes a resident was distressed by comments staff made to the person if the relatives complained. The pre-inspection questionnaire shows that 27 complaints have been received in the last 12 months, of which 21 were either substantiated or partially substantiated. Over half of the relatives completing comment cards had felt the need to make complaints. Staff spoken to are aware of issues of abuse and confirmed that some training has taken place in this area. Not all could identify what the gifts policy for the home was, but said that they would not accept anything or would inform the manager if token gifts were offered. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 15 Concern was expressed about some unprofessional staff conduct in showing concern and care for a resident. Four relatives say they have witnessed prolonged delays in securing the assistance necessary to manage continence when call bells are used, up to 25 minutes being reported while two relatives were present. Some staff confirmed that there were times when they were not able to respond to call bells as promptly as they would wish and one person agreed there was a possibility that the delay could be as much as 20 minutes. This has resulted in distress and upset to residents according to their relatives. Residents did not confirm this, two of the four spoken to not using their bells. Four minutes was the longest a call bell sounded without being cancelled during the course of the inspection (an improvement on 8 minutes at the last unannounced inspection). Relatives and residents say that, when staff do assist, they do so in a kind and caring manner. The system for recording monies brought into the home by relatives and handed over for safekeeping was examined. The administrator retains clear records of deposits, countersigned on receipt, and with records of outgoings. Receipts were matched against expenditure and balances of two person’s cash held were checked at random and found to be accurate. There is good practice in this area. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 standard(s) 19 and 26 There are some issues which affecting the safety of the environment, although it is generally well maintained. The home was clean at inspection, although there are some concerns for hygiene. EVIDENCE: There is a wooden seat turned over in the courtyard area, and the bird table is in two pieces. In the lounge of the Shannon unit the carpet is damaged along a join and presents a potential trip hazard. A join has also opened up in the flooring of one of the bathrooms. The lower glazed panel of a rear fire exit door has been damaged and is currently sealed with tape. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 17 Cushions had been removed from a number of armchairs in the Shannon Unit, following difficulties with continence. This temporarily compromised facilities available. A bolt was noted as fixed to the exterior of a bathroom. This is said to be so that residents do not wander in when the floor is wet and may be slippery. The privacy bolt fitted could be used for brief periods in such circumstances and is not open to “misinterpretation”. Some redecoration has taken place and further work was in progress during the inspection, to redecorate vacant bedrooms. Overall, the décor is in good order. Externally the grass had been cut around the building, and the maintenance person was in the process of putting winter bedding plants into containers to enhance the appearance of the grounds. The home was clean when inspected, although there were two areas where there were strong odours associated with difficulties managing continence. Relatives, both at interview and in comment cards, said that bedroom carpets were not always clean and one said in a letter that the bedroom often had an offensive odour. Other feedback was that tables in the rooms were not always clean and wiped, and that cobwebs accumulated. One visiting health professional said that the home was clean. The laundry was appropriately equipped and the staff member responsible had information about residents who carried infection and needed additional care taken when laundering items. The laundry room was clean and tidy. Inspectors were concerned however at the different responses given about the numbers of people who were affected by MRSA presenting a risk for infection control. Additionally, relatives confirmed that continence pads are not always properly managed (see “Health and Personal Care” section). They added that there were occasions when they had identified from wetness and odour that wet continence pads had been placed on top of bedlinen. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staffing levels are not adequate to meet the needs of residents. Their ability to deliver consistent care to meet needs and function well as a team is further compromised by poor morale and high turnover. Recruitment procedures have improved to protect residents, with minor shortfalls. EVIDENCE: The duty roster shows that the minimum staffing levels required by the staffing notice when the home was originally registered by the health authority are adhered to. However, these are minimum levels. Residents say that staff are very busy, and both residents and relatives say that the home is short staffed. When the numbers of residents fall, the staffing hours available are reduced on the owners instructions, based on information from the manager. Staff say that although numbers of residents have gone down, the number of people needing a lot of help with personal care tasks, moving and handling, and eating their meals, has not significantly declined. Relatives perceive this issue as beyond the immediate control of the manager. Relatives identify staff turnover as a problem. Over three quarters of those completing comment cards say that there are not always sufficient staff on duty. Concerns about staffing levels and poor morale were confirmed by relatives spoken to on the day, and by staff. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 19 The pre-inspection questionnaire, and discussion with the manager shows that 28 staff have left the home in the last 12 months. Four staff had left between the submission of the pre-inspection questionnaire received on 5th October, and the date of the inspection (18th October). A variety of reasons were given, including expiry of Visas or work permits for overseas staff, emigration, and obtaining alternative employment. Of the 28 care and nursing staff listed on the pre-inspection questionnaire, 15 have worked at the home for one year or less, and 8 of these for less than six months. These 8 people (almost one quarter of the care team) are nominally still completing their foundation training. Both staff and relatives say that morale is poor. The manager is aware that teamwork on occasions is difficult to achieve. Some staff say that they do not feel valued for the work that they do. Copies of current and previous duty rosters were examined after the inspection, as were staff “signing in” records. These do not consistently correspond, with some staff appearing on the duty roster but not signed in, and with some staff who do not appear on the duty roster, signing in to say that they are present and working shift. The duty roster does not therefore reflect whether the shifts were actually worked as shown and neither record can be relied upon to show the actual staffing levels in the home at any one time. The manager confirms that the minimum staffing levels set out in the old staffing notice, are adhered to. Four staff files were examined. One person did not have a written explanation for a gap in employment record of two years. The remainder showed that checks had been made properly and contained necessary records. The manager says that staff do not start work until PovaFirst confirmations are received (showing that people are not listed on the register of those who are unsuitable to work with vulnerable adults), and that they do not work alone with residents. Records do not yet show which appropriately checked staff members will be supervising these workers pending receipt of the full enhanced Criminal Records Bureau disclosures. Staff files show that mandatory training is completed, predominantly by video, including health and safety, moving and handling and fire safety. Records do not support that foundation standards as specified by the national training organisation are covered appropriately with evidence of competence retained. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 and 38 The home is managed by an appropriately registered person who is working towards achieving the required management qualification. The manager works hard to ensure that the service users benefit from the ethos, leadership versus management approach, but the homes efforts are compromised by staff turnover and low staff morale. Residents are consulted for their views so that the home can be run in their best interests. Their financial interests are safeguarded. Health and safety issues are promoted, in the interests of residents and staff. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 21 EVIDENCE: The manager has extensive nursing experience and is undertaking the appropriate management qualification. She has been registered with the Commission, and shows knowledge, training and experience as set out in standards. Some staff say that they do not feel valued for the work that they do, and discussion with relatives shows that they have expressed these views to visiting family members. Inspectors were informed that views and suggestions the staff made were not always responded to. There are annual surveys of residents and relatives, so that people get the chance to air their views about the service. The current survey has just been undertaken and the results are not yet back, according to the regional manager. The regional manager makes regular visits during which she takes note of views and comments expressed by both residents and staff. Some requirements made as a result of the Commission’s inspections have not been progressed within agreed timescales. There are relevant systems for ensuring that residents’ money is safeguarded where this is held on their behalf. See section regarding complaints and protection. There is a range of appropriate checks in place for the safety of appliances, for testing of fire detection systems and evacuation procedures, and for risk assessments of working practices. A sample was checked at random. The risk posed by a damaged carpet, broken wooden items in the garden etc, is covered under other standards and not within the elements of this standard. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 2 3 x 3 x x 3 Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15(2) Requirement The registered persons must ensure that where changes are identified, care plans are updated promptly and are consistent with assessments. OUTSTANDING SINCE LAST INSPECTION WITH TIMESCALE OF END JUNE 2005 NOT MET.. The registered persons must ensure that personal care needs are appropriately met. The registered persons must ensure that residents and/or their representatives are consulted about the care that they need and involved in review. OUTSTANDING SINCE LAST INSPECTION WITH TIMESCALE OF END JULY 2005 NOT MET.. The registered persons must ensure that residents health care needs in terms of nutrition are not compromised by weight gain/loss. OUSTANDING SINCE LAST INSPECTION WITH TIMESCALE OF END JUNE 2005 NOT MET. The registered persons must take action to ensure that continence is promoted, with due Timescale for action 31/12/05 2. 3. 7 7 12, 15 12(3) and 15(2) 30/11/05 31/12/05 4. 8 12(1), 16(2)(i) 30/11/05 5. 8 and 18 12 30/11/05 Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 24 6. 18 12 7. 19 23 8. 9. 19 19 23, 13(4) 23, 13(4) 10. 11. 12. 19 19 27 23 13(6) 12, 18(1) 13. 27 17(2) Sched 4 14. 29 19, Sched 2 as amended 18(1) 15. 30 regard to the dignity of residents. The registered persons should ensure by training or other means, that staff are aware of the importance of good professional conduct and boundaries when dealing with residents. The registered persons must ensure that damaged items in the grounds are repaired/replaced. The registered persons must replace or repair the damaged carpet in Shannon lounge. The registered persons must arrange for the repair of the opening seam to bathroom flooring (or replace it should this not be possible). The registered persons must replace the damaged glazed panel to the exterior rear door. The registered persons must remove bolts from the exterior of facilities used by residents. The registered persons must review staffing levels and dependency, and demonstrate that the numbers and skills of staff are adequate to meet the needs of residents. OUTSTANDING FROM LAST INSPECTION WITH TIMESCALE OF END JUNE 2005 NOT MET.. The registered person must keep a record of the duty roster of persons working at the home, and a record of whether the roster was actually worked. The registered persons must ensure that written explanations of gaps in employment history are obtained in all cases. The registered persons must ensure that foundation training covering the relevant standards 30/11/05 30/11/05 31/01/06 31/01/06 31/01/06 30/11/05 30/11/05 30/11/05 30/11/05 31/01/06 Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 25 is completed and that staff are assessed as competent. 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. Refer to Standard 16 19 27 29 Good Practice Recommendations The registered persons should establish methods of fostering an open complaints culture. The registered persons should ensure sufficient impervious liners and additional seat covers for armchairs (or spare cushions) are available for use. The registered persons should explore methods of encouraging staff retention. The registered persons should be able to show how staff are supervised on each shift, pending full CRB disclosure, and by whom. Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 26 Commission for Social Care Inspection 3rd Floor Cavell House St Crsipins Road Norwich NR3 1YF 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 Sanford House Nursing Home I55 s15678 Sanford House v246963 AN 181005(4).doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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