Care Home: Sandringham Care Home with Nursing

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What the care home does well The home receives good information about prospective service users prior to a decision being made for the person to move in. This means that the home is confident that they can meet the person`s needs. Care plans are written to include good detail and in a way that guides staff to deliver care appropriately and in a way that the service user prefers. This ensures that service users` receive care in a consistent way and appropriate to their needs. Staff are well trained and work with service users in a sensitive and respectful way. One family member said, "The staff are brilliant they always keep us well informed about my X. When they were ill they sat with them for 24 hours and kept me informed of their progress." A service user said, "The staff were very good whilst I was ill, they stayed with me constantly." A great effort has been made to use the communal areas of the home in an effective way. The large passageways include organised groups of easy chairs and small tables that accommodate small groups of people to sit and chat, listen to music and meet up with visitors. Chairs in the lounge areas are organised in a similar way, so that service users can watch TV if they wish, be part of an activity group or sit and chat with each other without disturbing the people around them. What has improved since the last inspection? The home has worked closely with the PCT (Primary Care Trust) to improve how medicines are stored and administered in the home. With their guidance, over the past 12 months the home has reviewed the home`s medication policies. Regular drug audits have been introduced and all staff have received training on the appropriate storing of medication and the importance of recording and reporting the temperatures in the drug storage areas. In addition to this all qualified and senior staff are supervised during medication rounds to ensure that good practice is maintained. The home has seriously addressed past poor practice in the home by following the local authority`s safeguarding procedures and the home`s disciplinary procedures. So that good care practice is promoted staff receive twenty minutes training sessions each day to include areas related to personal care, hygiene and the promotion of dignity and respect. This sort of direct supervision has proved to be effective with good outcomes for service users. Staff are now more aware of the codes of practice and the standards that must be met and as an outcome of this service users are treat with respect and their dignity is promoted. The way care plans are developed and recorded has improved. So that good recording is promoted the managers have received training in recording and care planning and this has been cascaded down to other members of staff through training sessions and supervision sessions. Over the past 12 months the home has employed two new activities organisers who have introduced more activities to the home. Families and friends are also encouraged to take part in activities in the home and this was particularly successful at the summer fayre when many families attended. A monthly news letter has been developed so that service users, their families and friends are informed of forth coming events in the home and a snoozle room has been developed so that service users have somewhere to go to relax quietly. So that the home is run well and so that service users receive good care consistently, the home has reviewed the staffing and management structure. Changes have taken place so that staff are more directly supervised and supported. Staff and service users spoke positively about the changes that have taken place in the home over the past 12 months and the relationships that have developed between them and the new manager. One member of staff said, "I have seen many changes in the home over the years, some good some bad, but since we have got the unit managers and the new registered manager the home has improved 110%." What the care home could do better: When a service user has a special dietary need their actual food in take should be recorded and monitored so that their health and welfare is maintained and promoted. Staff must ensure that they follow effective infection control and safety procedures when disposing of clinical waste into the clinical waste bins outside of the building. By keeping the bin lids tightly shut at all times will limit any possibility of the spread of infection. CARE HOMES FOR OLDER PEOPLE Sandringham Care Home with Nursing Escomb Road Bishop Auckland Co Durham DL14 6HT Lead Inspector Elsie Allnutt Key Unannounced Inspection 25th and 26th February 2009 10:00 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 Sandringham Care Home with Nursing DS0000063946.V374482.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. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandringham Care Home with Nursing Address Escomb Road Bishop Auckland Co Durham DL14 6HT 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) 01388 660966 01388 660967 pkilburn@ladhar.co.uk Ladhar Group Homes Jean Heseltine Care Home 90 Category(ies) of Dementia (31), Dementia - over 65 years of age registration, with number (35), Old age, not falling within any other of places category (24) Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 2Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing – Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category – Code OP, maximum number of places 92 Dementia – Code DE, maximum number of places 92 1. 2. The maximum number of service users who can be accommodated is: 92 1. The registered person may provide the following category of service only: Care Home with Nursing – Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category – Code OP, maximum number of places 92 Dementia – Code DE, maximum number of places 92 2. The maximum number of service users who can be accommodated is: 92 Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 5 Date of last inspection 17th January 2008 Brief Description of the Service: Sandringham Care home is a care home with Nursing including Dementia opened in May 2005 and provides accommodation for 92 older persons. The building is purpose built and provides accommodation on three floors. The home is located near to the general hospital and town centre. The home provides safe accessible outdoor areas with seating for service users to enjoy. The current range of fees is from £434.50 to £603.98. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 25th February and 26th February 2009 During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: The home receives good information about prospective service users prior to a decision being made for the person to move in. This means that the home is confident that they can meet the person’s needs. Care plans are written to include good detail and in a way that guides staff to deliver care appropriately and in a way that the service user prefers. This ensures that service users’ receive care in a consistent way and appropriate to their needs. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 7 Staff are well trained and work with service users in a sensitive and respectful way. One family member said, “The staff are brilliant they always keep us well informed about my X. When they were ill they sat with them for 24 hours and kept me informed of their progress.” A service user said, “The staff were very good whilst I was ill, they stayed with me constantly.” A great effort has been made to use the communal areas of the home in an effective way. The large passageways include organised groups of easy chairs and small tables that accommodate small groups of people to sit and chat, listen to music and meet up with visitors. Chairs in the lounge areas are organised in a similar way, so that service users can watch TV if they wish, be part of an activity group or sit and chat with each other without disturbing the people around them. What has improved since the last inspection? The home has worked closely with the PCT (Primary Care Trust) to improve how medicines are stored and administered in the home. With their guidance, over the past 12 months the home has reviewed the home’s medication policies. Regular drug audits have been introduced and all staff have received training on the appropriate storing of medication and the importance of recording and reporting the temperatures in the drug storage areas. In addition to this all qualified and senior staff are supervised during medication rounds to ensure that good practice is maintained. The home has seriously addressed past poor practice in the home by following the local authority’s safeguarding procedures and the home’s disciplinary procedures. So that good care practice is promoted staff receive twenty minutes training sessions each day to include areas related to personal care, hygiene and the promotion of dignity and respect. This sort of direct supervision has proved to be effective with good outcomes for service users. Staff are now more aware of the codes of practice and the standards that must be met and as an outcome of this service users are treat with respect and their dignity is promoted. The way care plans are developed and recorded has improved. So that good recording is promoted the managers have received training in recording and care planning and this has been cascaded down to other members of staff through training sessions and supervision sessions. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 8 Over the past 12 months the home has employed two new activities organisers who have introduced more activities to the home. Families and friends are also encouraged to take part in activities in the home and this was particularly successful at the summer fayre when many families attended. A monthly news letter has been developed so that service users, their families and friends are informed of forth coming events in the home and a snoozle room has been developed so that service users have somewhere to go to relax quietly. So that the home is run well and so that service users receive good care consistently, the home has reviewed the staffing and management structure. Changes have taken place so that staff are more directly supervised and supported. Staff and service users spoke positively about the changes that have taken place in the home over the past 12 months and the relationships that have developed between them and the new manager. One member of staff said, “I have seen many changes in the home over the years, some good some bad, but since we have got the unit managers and the new registered manager the home has improved 110 .” What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 9 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 Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Pre-admission assessments received from the referring agencies and carried out by the home demonstrate service users’ needs and assists the home to make informed judgements as to whether they can meet these needs. This ensures that the service user receives the appropriate sort of care and support from the home. EVIDENCE: Prior to making a decision that they can meet their needs the home receives comprehensive information from the referring agency and other people involved in an individual’s care. For example for one person information from the McMillan nurse involved in their care and for another a hospital discharge letter were received. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 11 In addition to this a senior representative from the home also visits the person and carries out a full assessment of need. The assessment process addresses any risks that may be identified during the process and from this the necessary strategies are put in place in an attempt to reduce the risk. For example for one person, who was assessed as having a risk to developing pressure sores, this meant the home making sure that the right sort of pressure relief equipment was in place prior to them moving in. When the decision is made that the home can meet a prospective resident’s needs, a letter is sent out to the person to confirm this. The assessment process is ongoing and the information gathered is used to develop care plans that reflect the assessed needs. This home does not provide intermediate care. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Suitable and effective arrangements are in place to meet service users’ healthcare and social needs and good procedures are in place for the safe administration of medicines. This promotes the health and welfare of the service users and ensures that a consistent service is delivered. EVIDENCE: Care plans have been developed for each service user. The assessment process determines the care interventions that are needed and service users and their families are involved in their development. Information about how the individual likes to be supported, their needs and their expectations are discussed to ensure that the care plans are person centred and include the information necessary. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 13 Any risks identified are assessed and guidelines regarding the strategies to be used to reduce the risk are included as part of the plan of care. This means that staff have enough information to guide them appropriately and consistently when supporting the person. To ensure that the care plans are recorded clearly, accurately and appropriately and that they maintain the required standard, a clear audit trail is in place. The management team monitors all care plans three monthly, during which time if any changes in need have been identified, the manager addresses them. In addition to this senior care staff review the care plans monthly and an annual review takes place annually when the service user, their family/friends and the care manager are invited to discuss the plans in place. The care plans are written with good detail so that care staff have clear guidelines to follow in relation to the individual’s preferences and needs. For example for one person, their preferred dress for bed and the type of bedding preferred is recorded and in addition to this there is good information relating to the person’s personal care needs and the preferences they have in relation to these. For another a care plan regarding special dietary needs includes good information and guidance regarding maintaining a good diet. The size of portions the person prefers, foods needed to be encouraged between meals and guidance for staff to encourage the person to eat are all included. It was noted however that although the daily monitoring notes recorded that the person had “taken a good diet” it did not specify the sort of foods and the quantities taken. So that the actual amount of food in take can be monitored this sort of detail should be recorded. The home has developed good relationships with other professionals and when needed seek their professional advice and guidance. This informs staff how to deal with situations in a professional way. For example when a person demonstrates challenging behaviour a CPN (Community Psychiatric Nurse) or Psychiatrist is contacted and the guidance given is recorded in the care plan. The guidance is then followed and staff supports the person in a consistent way. For one person ABC charts were in place so that the triggers to the behaviour could be monitored and reported back to the professional involved. Staff are well informed and receive the necessary training regarding service users’ diverse needs. This is reflected in the standard of care practices carried out and the competent and sensitive approach to service users. All staff have received training regarding challenging behaviour and in the near future staff are to receive training regarding “breakaway techniques.” Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Staff encourage service users to exercise and maintain choice and control over their lives by arranging activities and other forms of stimulation, while also maintaining contact with family and friends. This means that service users are provided with different opportunities to lead fulfilling lifestyles and do not become socially isolated or bored. Service users’ individual dietary needs are met by being served food that is appropriate to their needs, healthy and nutritious. EVIDENCE: Two activity organisers are employed to arrange and coordinate activities throughout the home. Service users are informed about these from notices, detailing individual events, displayed around the home. Photographs displayed throughout the home, of recent and past events and activities that have taken place, are there for residents, friends, families and visitors to see. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 15 Events include visits to local places of interest for example Butterfly World and the Centre of Life, trips to the local supermarket and local cafes, pamper days and chair exercises. Service users’ hobbies and interests are identified on admission and these are recorded in individual care plans. Several service users were involved in various individual activities reading newspapers, knitting, doing puzzles and one person spent time on their computer playing a game of “patience.” Although some service users chose to carry out these activities in the privacy of their rooms others sat in the many different areas throughout the home. One person that was knitting in their room said that they also join in the knitting club that takes place in the home. In one of the lounges the furniture was arranged to accommodate a pamper session. Several foot spas were arranged so that the people involved could see each other and discuss their experience. One service user was excited on approaching the room saying, “I am going to have my feet soaked and have my nails done at the same time.” Other service users discussed activities they go to in the local community including a local tea dance and a Men’s Club. Visitors spoke highly of the home and the warm welcome they receive every time they visit. One person said, “ This is an excellent home, the staff are brilliant, we are always given a warm welcome when we come.” The cook leads a competent kitchen staff team and is aware of the diverse dietary needs of the service users and the training needs of the staff to address these. Staff are appropriately allocated to support service users during mealtimes when service users sit at attractively set tables. A choice of meals are offered each day and service users spoke highly of these. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Effective arrangements are in place to help protect service users from abuse and to address complaints and concerns about the service seriously. EVIDENCE: The home has a comprehensive complaints procedure of which service users and their representatives are aware. Service users are confident that their concerns or complaints are addressed appropriately and they are encouraged to discuss their concerns on a daily basis and these are addressed directly. The complaints file demonstrates that complaints have been taken seriously and addressed appropriately. One person said, “I let the home know if I am not satisfied or have a concern or complaint and they usually listen.” Staff receive training regarding the local authority’s safeguarding adults procedures and they are aware of the action they would take if an abusive incident was observed or reported to them. A copy of the procedures is available in the home to which staff can make reference. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 17 Over the past 12 months there have been several allegations made regarding poor practice in the home. Two of these were made anonymously and were investigated by the CSCI (Commission for Social Care Inspection) during an unannounced random visit. The home has addressed all of the complaints and allegations made seriously following the local authority’s safeguarding procedures and when appropriate by following the home’s disciplinary procedures. As an outcome care practice in the home has improved and service users receive care only from people who are fit to work in the role as a carer. Service users are encouraged to look after their own finances when appropriate. For those who need support with this, comprehensive procedures are in place for staff to follow and these help safeguard service users from the possibility of financial abuse. The records are kept by the home’s administrator and monitored by the manager. A monthly reconciliation report is carried out and submitted to the head office. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, warm and well maintained, offering service users a homely environment in which to live, while at the same it promotes their general welfare, dignity and comfort. EVIDENCE: The home is decorated and furnished to a very high standard and the cleanliness throughout reflects effective cleaning routines that are discreetly and safely carried out by the domestic staff team. Comments made by service users about the home include: “The place is always spotless.” “This is a very clean home.” Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 19 The well-kept, safe and comfortable environment reflects a comprehensive maintenance programme. A competent maintenance person is employed to deal with maintenance issues around the home, including day-to-day repairs and the monitoring of the maintenance contracts for the home’s gas, electric and water supplies. In addition to this he is responsible for monitoring health and safety issues including fire safety and hot water checks. Clear records of these are in place. Access into and within the home is good and meets the needs of those service users who have mobility difficulties and who use walking aids such as Zimmer frames or wheelchairs. Service users’ independence and privacy is promoted throughout the home. There is a variety of bathing facilities, some with lifting appliances and all bedroom and bathroom doors have locks. Bedrooms are individually decorated to reflect individual taste. Service users are encouraged to furnish their rooms with personal items, resulting in this area being familiar to them, as well as having the opportunity to express their individual personalities. Good progress is being made to develop the dementia care unit so that service users can orientate themselves effectively and be content and independent in their environment. Staff receive training relating to infection control, however it was noted that the clinical waste bin outside of the home was overflowing, resulting in the lid being unable to close. This was brought to the attention of the manager as an infection control issue. The manager addressed the issue immediately. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a competent and qualified staff complement that effectively meets the service users’ care needs and the robust recruitment procedures ensures that their welfare and interests are protected. EVIDENCE: The home employs a team of staff with diverse experience and qualifications. The number on duty meets the needs of the service users currently living at the home. The staffing structure has recently been reviewed so that there is a manager on each of the three units who is responsible for leading a team of three carers. In addition to the care staff there is a sufficient number of domestic and kitchen staff employed. The staff are enthusiastic about their work and made the following comments: “It’s a lovely place to work.” “Things have changed so much in this home, it’s good.” “We work as a team, I am very happy working here.” “We get lots of training opportunities.” Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 21 Staff felt that they receive the opportunity to develop their skills and learn about new ideas. There is a positive approach to training and the manager is in contact with different training organisations and funding agencies, resulting in wellestablished training programmes that have resulted in a well-qualified staff team. Staff are up to date with mandatory training and attend training courses to reflect the needs of the service users and in addition to this they receive in house training regarding the principles of care and in particular the promotion of dignity and privacy. All staff have, or are in the process of doing, the distant learning course related to dementia care. Care practices observed in the home reflect the skill and dedication of a well trained and motivated staff team. Staff were observed sensitively interacting with service users and working as a team. Staff files demonstrate comprehensive induction systems as well as other training courses attended. Appropriate recruitment records of staff recently employed demonstrate that the home’s robust recruitment procedures are followed. Application forms identifying a clear, up to date record of employment, two written references and a satisfactory CRB (Criminal Records Bureau) checks are in place. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent well-qualified senior team and an effective quality assurance system supports the manager to maintain good management routines that deliver a service in their best interests of the service users. EVIDENCE: The manager worked as a unit manager on the nursing units prior to being promoted to the role of home manager. She is registered with the CSCI (Commission with Social Care Inspection), has the Registered Managers Award (RMA) and a nursing qualification. There are three unit managers who are all qualified nurses and have qualifications in social care, who support the manager in her role. One who deputises for the manager in her absence is Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 23 working towards the new manager’s qualification the Leadership in Management Award. This means that there is always a competent manager on duty to lead the staff team. There are clear systems in place that reflect the manager’s competent leadership skills. Senior staff have delegated responsibilities, that as an outcome, supports the manager in her role. Staffs’ competencies and skills are recognised and they are empowered to take responsibility of their role and as a result carry out their roles competently and with confidence. They are supervised closely and sensitively. Arrangements are in place for the manager to receive monthly visits from a senior company manager to assist her with monitoring the quality assurance systems in the home. The quality assurance system in place is effective and ensures that the home’s policies and procedures are put into practice and that the service is delivered in the best interests of the service users. The manager has attended a three-day training programme to prepare for The Investors in People Award programme. Good arrangements are in place to safeguard residents’ monies held in the home. Comprehensive procedures are followed and recorded appropriately. Risks identified throughout the home are monitored and addressed well. Fire safety is practiced appropriately and accidents to both residents and staff are recorded and addressed satisfactorily. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 25 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 OP26 Regulation 13(3) Requirement The registered manager must ensure that safe practices are carried out regarding the disposal of clinical waste. Timescale for action 31/03/09 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 OP7 Good Practice Recommendations When a care plan is in place regarding a person’s special dietary need the actual amount of food taken should be recorded so that the actual food intake can be monitored. Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandringham Care Home with Nursing DS0000063946.V374482.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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