Care Home: Sandrock House

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What the care home does well Good assessments are carried out on all perspective residents and people are only admitted if the home is able to meet their needs. People`s plans of care clearly identify their needs and give details of how to meet their needs. People`s choice and capacity are also taken into consideration to ensure they have choices and make decisions regarding their care. A varied, balanced and wholesome diet was provided for the people with good choices available. One person told us, "The meals are lovely, I always enjoy them". The environment was maintained to an excellent standard. It was homely and well decorated. The standard of cleanliness observed during the visit was excellent. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. What has improved since the last inspection? The manager had worked very hard on improving the care provided to ensure the health care needs of the people are met. A new staffing structure was in place with a deputy manager was to be appointed to support the manager and ensure people`s needs were met. The maintenance and renewal programme had continued and many rooms had been redecorated to a high standard and new furniture purchased. This ensued a high standard was continually maintained for the people living in Sandrock House. A training programme had been implemented and all staff had received mandatory training to ensure people`s needs were met. An activities co-ordinator is now in post and people told us that she is very good and gradually introducing different activities both group and 1 to 1 sessions, this ensured peoples social needs were being met. What the care home could do better: Ensure the works identified in the action plan submitted to the commission by the providers are carried out. This will ensure peoples needs continue to be met once the additional ten beds are registered. CARE HOMES FOR OLDER PEOPLE Sandrock House 53 Bawtry Road Bessacarr Doncaster South Yorkshire DN4 7AA Lead Inspector Sarah Powell Key Unannounced Inspection 09:20 12th & 18th June 2008 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sandrock House DS0000007971.V366564.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. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandrock House Address 53 Bawtry Road Bessacarr Doncaster South Yorkshire DN4 7AA 01302 535634 F/P01302 535634 NONE 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) Sherwood Care Homes Limited Joyce Richardson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th June 2007 Brief Description of the Service: Sandrock House is a care home providing accommodation and personal care for 20 service users in a converted building with an extension at the rear. The home is in Bessacarr, Doncaster and is close to local amenities. Sherwood Care Homes Ltd owns the home. All bedrooms are single with en-suite toilet facilities except for one. Accommodation is provided over two floors. The upper floor is accessed by a stair lift. There are two pleasant lounges and a dining area. The gardens are well kept and people living at the home enjoy sitting out. People who are interested in staying at the home are given information about the home in the form of a brochure. All people that come to live at Sandrock House are provided with a Service User Guide. The latest inspection report from the Commission for Social Care Inspection is available in the home. The current fees charged are £385.00 per week. Additional charges are made for hairdressing, chiropody and personal toiletries and newspapers. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. This was an unannounced visit, which took place on the 12 & 18th June 2008 it commenced at 09:20 on the first day and finished at 13:45, the second day commenced at 11:15 and finished at 14:30 hours. The visit included talking with people living at the home, a number of relatives, the manager, the providers and six staff. A walk around the building to gain an overview of the facilities and we checked a number of records. Some surveys forms were sent to people who live at the home and their relatives. At the time of writing this report two had been returned to the Commission. The comments received were very positive. The manager completed an annual quality assurance assessment (AQAA) and returned this prior to the visit this focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. What the service does well: Good assessments are carried out on all perspective residents and people are only admitted if the home is able to meet their needs. People’s plans of care clearly identify their needs and give details of how to meet their needs. People’s choice and capacity are also taken into consideration to ensure they have choices and make decisions regarding their care. A varied, balanced and wholesome diet was provided for the people with good choices available. One person told us, “The meals are lovely, I always enjoy them”. The environment was maintained to an excellent standard. It was homely and well decorated. The standard of cleanliness observed during the visit was excellent. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 6 were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. What has improved since the last inspection? 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. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home had their needs assessed prior to moving into the home. EVIDENCE: Suitably qualified staff carried out the pre admission assessments on people who wanted to move into the home. The assessments were very detailed with all peoples needs identified, ensuring that the home could meet their needs before a place was offered to them. The home does not offer intermediate care so standard 6 does not apply. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person in the home had a plan of care with clearly identified needs, these were met, and people were treated with respect. Medication procedures protected people. EVIDENCE: Two people in the home were case tracked; this meant their plans of care were looked at in detail. The plans had identified the needs of the people with good recordings of the measures to take to meet their needs. The plans were regularly reviewed; people and their relatives were involved in this process. This ensured their views were listened to and their needs met. Many care plans had recently been rewritten to include evidence that the new mental capacity act had been taken into consideration, with regard to peoples capacity and Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 10 choices this ensured peoples needs were identified and met allowing them to make choices and decisions regarding their care. All health care needs were met and regular input from health care professionals was obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. People were treated with respect and privacy and dignity upheld. During the visit we observed staff interacting very well with people and their relatives. One relative told us, “The staff are good they look after people very well, I am very happy with the care my relative receives”. One person told us, “The staff are lovely and look after me very well”. Medication policies and procedures safeguarded the people. Medication was well documented on receipt, administration and return. All staff who administer medication regularly receive medication training and undergo competency assessments to ensue people are protected. The manager and senior care staff had recently audited medication and further improved systems to ensure they safeguarded the people. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 11 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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People exercised choice and control over their daily lives and activities ensuring their needs were met. EVIDENCE: An activities co-ordinator was employed for 12 hours each week. Activities were varied and changed depending on the choices of the people who attended on the day. One to one activities were also provided to ensure all people’s needs were met. The manager told us that outings were being considered. People were being asked what they would like to do, a boat trip was being considered and this would hopefully be implemented in the summer to meet people’s needs. The activity co-ordinator produced a newsletter every two months for the people and their relatives to keep them informed as to what was happening in Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 12 the home. This was a very informative letter and people spoken to say they enjoyed reading the newsletter. The people and their relatives we spoke to all said that contact with family, friends and the local community were encouraged by the staff and relatives were always made welcome. A varied, balanced and wholesome diet was provided for the people with good choices available. We observed a meal, which was well presented, there was good communication to the people from staff when it was served, seconds were offered, people were asked if they were finished before plates were taken and a choice of drinks were also offered. This ensured peoples needs and choices were met. The provider told us that when the extension was completed the kitchen assistant hours would increase to 6 hours a day to ensure people’s needs were met. One person told us, “The meals are lovely, I always enjoy them”. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 13 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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived in the home were listened to and protected. EVIDENCE: There was a comprehensive complaints procedure, which was clearly displayed, in the entrance hall. All people we spoke to were aware of the procedure and told us they would either speak directly with the manager or staff. The manager had received two concerns; a third was raised through the Commission for Social Care Inspection. Good records were kept of the investigations and outcomes. This showed they had been fully investigated, acted on, taken seriously and resolved. All staff had received training in adult protection; all staff we spoke to had a good knowledge of the procedures and what to do should an incident occur. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 14 Staff were also aware of the whistle blowing policy, which safeguards people in the home. The manager also had a copy of the local authority safeguarding policy. This ensured the staff were aware of the local procedure. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained clean, pleasant and comfortable ensuring people lived in a safe environment. EVIDENCE: The environment was maintained to an excellent standard. It was homely and well decorated. The standard of cleanliness observed during the visit was excellent. There was a maintenance and renewal programme, many rooms had been redecorated since the last visit and new furniture purchased. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 16 The providers were extending the premises to provide a further ten bedrooms. This work was nearly completed. This would also provide an additional two communal bathrooms. It was therefore proposed by the providers that the existing small bathroom, that was not suitable for use, be converted to a sluice/store room. This would be beneficial to the people at Sandrock House as there was lack of storage facilities. The providers have also taken steps to ensure the laundry facilities will be able to meet the demands of an additional ten people. An additional washer and dryer will be installed once the building work is completed. An additional domestic will also be recruited. This will ensure people’s needs are met. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were appropriately trained, the recruitment procedures were robust ensuring people were in safe hands at all times, had their needs met and were protected. EVIDENCE: The staff on duty met people’s needs and the skill mix was appropriate to the assessed needs of people. A new deputy was to be appointed following completion of the extension, which would provide a good management structure, to ensure people’s needs were met. A number of people told us that there only concern was that at some times there was not enough staff on duty particularly at weekends, because of this sometimes you had to wait a while for assistance when required. Mandatory training was up to date and there was clear evidence that this was maintained and refresher courses completed within timescales. The manager had worked very hard on the training this year to ensure staff were appropriately trained to meet peoples needs. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 18 The provider carried out the induction for all new staff following the skills for care induction; this ensured all new staff had the appropriate skills to meet people’s needs. 67 of staff had an NVQ qualification and a further 4 care staff were currently completing NVQ level 2 this would take the total to over 90 ensuring people were in safe hand at all times. A thorough recruitment procedure was in place, two staff files were seen on the day of the visit and contained all the required information. Protecting people who lived there. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration safeguards people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: The manager was qualified and experienced to run the home. She had achieved the registered managers award and continually kept herself updated to ensure the homes stated purpose, aims and objectives were met. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 20 One person told us, “The staff all work well together and we are looked after well”. Staff told us, “The manager and provider are very good, it is a good place to work and there is good communication between management and staff”. Quality monitoring was carried out; the manager did regular audits and had regularly sent quality-monitoring questionnaires to people in the home and their relatives. This ensured the home was run in the best interests of the people who lived there. The home managed some people’s finances and personal money. We checked one record, which was correct. The manager told us all records were maintained and all receipts were kept, ensuring peoples financial interests were safeguarded. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X 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 X 18 3 4 X 3 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 Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations To ensure the action plan which you submitted, which details requirements that will ensure the needs of the additional 10 people and existing people will be met is addressed. The staffing levels are looked at to ensure adequate staff are on duty to meet peoples needs. 2. OP27 Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 23 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 Sandrock House DS0000007971.V366564.R01.S.doc Version 5.2 Page 24 - 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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