Archived: Sandhall Park

Updated 7 February 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place over three days between 13 December 2017 and 3 January 2018. The first day was unannounced and we made arrangements to return on the following two days.

On the first day the inspection team consisted of one adult social care inspector and two experts-by-experience. The second and third day of the inspection were conducted by an adult social care inspector. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. One of the experts-by-experience had personal experience of working with people that had physical and/or sensory impairment and the other had knowledge of caring for people living with dementia.

Prior to the inspection we gathered information from the local authority in relation to safeguarding concerns and quality assurance visits that had taken place. We contacted five health professionals who had regular involvement with the service. We also considered information sent to us in the Provider Information Return form (PIR). This form is completed by the provider and gives us information on how the service is being run, any improvements that are planned and information on the management of the service.

During the inspection we spoke with ten people who used the service and nine of their relatives. We had discussions with four care assistants, three senior carers, the activities co-ordinator, catering staff, deputy manager, registered manager, operational manager and the regional manager. Following the inspection we spoke with another member of staff and also contacted two relatives for feedback.

As part of the inspection we carried out observations on both units of the home and completed a Short Observational Framework for Inspection (SOFI). SOFI allows us to observe and assess interactions taking place between people living at the service and the care workers. Information in relation to the management and running of the service was reviewed, this included recruitment, staffing, training and maintenance records.

Updated 7 February 2018

This inspection took place on 13 and 21 December 2017 and 3 January 2018. The first day was unannounced with a further two days announced.

Sandhall Park provides accommodation for up to 50 people who require support with their personal care. The service provided personal care and support for older people and people living with dementia. The premises are on ground floor level and split into two separate areas. The Honeysuckle area supports people with residential needs and Jasmine area supports people living with dementia. On the first day of the inspection there were 46 people living at this service.

The provider is required to have a registered manager in post. There was a registered manager and they had been in post since August 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection in December 2016 we rated the service Good. During this inspection we found the provider to be ‘Requires Improvement’ in safe and well-led. We found evidence to support that the provider was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Quality assurance systems and audits were in place. However, these did not identify all the issues we raised during the inspection. In addition, where the internal audits had highlighted areas that required improvements, at the time of our visit these had not been fully actioned.

People received care and support from care workers that had good knowledge about their needs and preferences. However, risk assessments when reviewed did not always take into account deterioration in people’s health needs and some scores were incorrectly totalled. Records showed us that people’s consent to their care was sought and documented in care plans.

People’s health care needs were recorded and monitored so that appropriate referrals could be made to health professionals for advice and guidance.

Relatives told us they always felt welcomed when they visited the home and that they had no restrictions around visiting times within reasonable hours of the day. The majority of relatives felt the communication was good and that they knew what was going on, although some felt concerns were not always addressed effectively.

Care workers completed online and face to face training courses. Senior care workers checked that staff completed refresher training to ensure that skills and knowledge were current. The majority of care workers felt supported, although we received mixed feedback about whether they would feel comfortable raising concerns to the registered manager.

Care workers received monthly supervisions and annual appraisals. Recruitment checks were conducted but improvements were required to make recruitment practices more robust.

Safeguarding concerns were recorded in accidents and incidents, and individual’s care folders. The central safeguarding log did not contain all the concerns, or always show actions taken or the lessons learnt.

Overall medicines were administered and stored safely. People were supported if necessary to attend their annual medicine reviews. However, some labels for creams did not include sufficient information to guide staff on where they should be applied. Records for pain relief were not monitored for their effectiveness and when required medicines protocols were not in place.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.