Inspection on 18/02/06 for The Robertson Sandie Home

This inspection was carried out on 18th February 2006.

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

The Robertson Sandie Home 15/08/06

The Robertson Sandie Home 23/06/05

The Robertson Sandie Home 15/02/05

The Robertson Sandie Home 29/09/04

The Robertson Sandie Home 04/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Robertson Sandie Home Vyner Road South Birkenhead Wirral CH43 7PR Lead Inspector Julie King Unannounced Inspection 18th February 2006 08:50 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 The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 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. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Robertson Sandie Home Address Vyner Road South Birkenhead Wirral CH43 7PR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 653 6613 Abbeyfield Wirral Extra Care Society Limited Pauline Susan O`Neill Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: The home is registered for personal care only. At the time of this inspection there were 14 service users resident in the home, which was observed to be clean, tidy and well maintained. Service users can access all parts of the home, including the well cared for gardens. The home is part of the Abbeyfield Charity group. The home is run in an open and inclusive way, both for service users and staff. All residents have private bedrooms, which are nicely furnished, and are encouraged to personalise their own rooms with furniture and photographs from home. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours, during which time resident’s care plans, staff personnel files, safety certificates and the environment were examined. The registered manager was not scheduled to be on duty, but came to the home to accompany the inspector, as did the Responsible Individual. This care service has evidenced significant improvement since the new management structure was put in place last year, and ongoing improvements were evident from the last inspection in June 2005. During this inspection all staff and most residents were spoken to by the inspector – all commented on how happy they are being at the home, and what a pleasant environment it was. What the service does well: What has improved since the last inspection? There have been ongoing improvements at Robertson- Sandie since the last inspection. The information available for residents has improved, as have the following; care planning, multidisciplinary healthcare team involvement, medication administration and management, record keeping, and the environment. The overall management of the home also evidences ongoing improvement and development, and staff morale and attitude was noticeably better. Residents spoken to told the inspector that “things are nice here” and they “are happy”. Staff also confirmed this. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 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. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 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 The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. The resident’s pre-admission assessment documentation is robust, this ensures that the skill mix of the workforce in the home can support the residents identified care needs. EVIDENCE: All residents in the home are provided with a statement of terms and conditions, plus a contact when they move in to the home on a permanent basis. Residents are also able to visit the home or have an overnight stay before they move in on a permanent basis. The home’s manager undertakes a pre admission assessment with residents before they are admitted to the home, to ensure care needs are identified. Other health care professionals known to the resident are also involved in the assessment. Care staff in the home have started to undertake more specialist care training, which is ongoing, to ensure that the assessed and changing care needs of the residents can be met. All staff training must be reflective of the needs of the The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 9 residents, and it is required that additional training be made available to both the staff and manager. It is strongly recommended that the pre-admission assessment is recorded in more detail on the assessment form. Some of the assessments seen were not detailed enough regarding specific care needs, even though the actual tool itself was comprehensive and covers all points as listed under NMS OP Standard 3. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. There is a clear care planning system in place for most residents. This provides staff with the information they need to satisfactorily meet the resident’s needs. Medication management is compliant with current good practice requirements and guidelines. EVIDENCE: It was evident that the resident’s needs are currently being met through examination of the care planning process and conversations with residents and staff. Individual care plans had been documented for each resident, and those seen were in the process of being updated and reviewed with the involvement of the individual resident as far as possible. Some improvements were seen in the care plan detail and in the way they are recorded on a daily basis. Systems are in place to ensure good communication between the care home, the NHS and other professionals involved in the care The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 11 of the residents. All this contributes to the safety and well being of the residents. A number of recommendations were given to the registered manager on how to improve the care plans. It was recommended that all entries on the daily reports are signed and timed, using the twenty-four hour clock. It was strongly recommended that all accidents and incidents are clearly cross-referenced in care plans as well as accident reports; and follow-up action should also be accurately documented. All nutritional risk assessments, in conjunction with weights of all residents should also be clearly recorded, and kept up to date. The new revised systems that are in place for the management of medications has proved to be successful, with medication findings as follows: • • • • • • • • • • Drugs of potential abuse counted and checked regularly, with records kept Controlled drugs stored, managed and recorded in accordance with current regulations Weekly NOMAD system in place – checked by the dispensing pharmacist Accurate records of all returns to pharmacy Training for all staff who administer medications New, updated policies and procedures for all aspects of medication management New, secure cupboards and storage areas for medications No gaps on medication administration records (MARs) Transcriptions double signed Three monthly pharmacist medication reviews The resident’s spoken to during the inspection all commented on the high standard of care they received. They confirmed they had access to various healthcare professionals as necessary, and stated that the care staff always respected their privacy and dignity by “treating me well” and “asking me what I want”. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Links with the local community are good, and they support and enrich resident’s social lives; however more activities are needed in-house on a dayto-day basis. The meals in Robertson-Sandie are good, offering both choice and variety, as well as catering for special dietary needs. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member complete an initial care plan, which includes a social history as well as referring to hobbies, food likes and dislikes information, etc. This information is used to plan organised activities for the resident. Visitors are allowed in the home at any reasonable time for day, residents may entertain their visitors, in the communal lounges, or in their own bedroom. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 13 The gardens have been tidied and are an ideal setting for residents to sit with their relatives, especially in the summer months. The residents informed the inspector that they enjoyed the variety of food in the home, and were looking forward to their lunch. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. An efficient complaint and adult protection policy and procedure was in place that helps ensure the safety and welfare of residents. EVIDENCE: Robertson-Sandie has an efficient complaints and adult protection policy and procedure in place which helps ensure the safety and welfare of residents. The residents, relatives and staff can access these when necessary. The procedures includes information on ‘whistle-blowing’, in accordance with the Department of Health ‘No Secrets’ guidelines. The CSCI has not received any complaints about this service since the previous inspection. Most of the staff have, or are in the process of completing training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. The residents all spoke highly of the staff team and said they “have no complaints about how I’m treated”, and “nothing is too much trouble”. Some advocacy information was available if required by residents or their relatives. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. The overall fabric of the building is of a good standard, with most resident’s rooms being highly personalized, providing residents with an attractive and homely place to live. EVIDENCE: Robertson-Sandie has pleasant gardens to the front and rear of the property that are accessible to residents. A patio area with seating, and a summer house in the rear garden is also provided. All communal areas and bedrooms were examined, and all were highly personalised, with many residents bringing in their own furniture and personal possessions. The overall fabric of the building is of a good standard. There is an ongoing programme of redecoration and refurbishment, with communal areas and resident’s bedrooms being done as needed. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 16 On the day of this unannounced inspection the home was clean and did not have any malodour. All recommendations and requirements from the Merseyside Fire Brigade safety officer (who accompanied the inspector on the previous inspection) have been implemented; and the home has recently had a full Health & Safety audit from an external company. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. There is now a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the residents. Further work is still necessary to fully comply with staff training and development. EVIDENCE: Since the previous inspection there has been further improvement in the staff personnel files and general recruitment practices. References were seen in all files, and CRB and POVA information was also evident. However it was recommended that copies of all information required for CRB purposes are held on staff files. The registered manager and responsible individual were clearly able to inform the inspector of their knowledge of the National Minimum Standards and accompanying regulations regarding the recruitment and retention of staff. Training and inductions, including specific training on the protection of vulnerable adults was seen for most staff. The manager has developed a training plan for all staff, accessing many external training providers. The range of training and development includes medication management, moving & handling, health & safety, pressure sore prevention and NVQ in Care. This improvement should continue to be built upon. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 18 The manager is also in the process of establishing “link people” to obtain additional information and training as needed. Their role will also extend to cascade new information to the remainder of the home’s staff. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38. The management of the home operate in an open and transparent way. Consultation has improved with residents and staff morale is high, resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: Since the previous inspection, the manager is now registered with the CSCI, and has many years of care home management. The manager has recently registered on an NVQ Level 4 Care Management programme, and hopes to complete this by summer 2006. Staff and residents informed the inspector that the home was being run in an open, positive and transparent way; both staff and residents have started having regular meetings with the manager; the meetings are minuted and actioned upon. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 20 It was noteworthy that positive comments and suggestions were made by all staff and all residents spoken to. Some quality assurance processes are in place although these should be further improved to fully comply with regulation. It is also important that all staff receive regular supervision in line with this standard. Patient’s monies are kept in separate, secure facilities, and records of all transactions were seen. Certificates for equipment, electric and risk assessments were seen to be up to date and valid; as was the fire risk assessment and related records. The annual gas safety certificate was out of date, having expired in December 2005. The responsible individual assured the inspector that this would be addressed as a priority, and an up to date, valid certificate will be forwarded on the CSCI as soon as possible. The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 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 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP28 Regulation 18 Requirement The registered person must ensure that all staff continue with, and complete relevant training and updates, specific to the current resident group. The registered person must continue with, and ensure that all staff are regularly supervised, with records of this kept. The registered person must ensure that all equipment at the care home is in safe working order at all times – refer to out of date gas safety certificate. Timescale for action 31/05/06 2. OP36 18 31/05/06 3. OP38 23 30/04/06 The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is strongly recommended that either the manager or responsible person audits all medication records initially at least once per week, then at greater intervals as needed; and detailed records of this audit are kept. It is strongly recommended that care plans are amalgamated into a more readable, organised format, with all documentation pertaining to each resident being held in one file only. It is recommended that all the documents and records as specified under The Care Homes Regulations 2001 as required for CRB processing are copied and held on staff personnel files. It is strongly recommended that medications are labelled on the actual box, bottle, vial, etc; rather than just on the container/box. 2. OP7 3. OP29 4. OP9 The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Robertson Sandie Home DS0000018960.V279880.R01.S.doc Version 5.1 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. 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