Archived: Sandhall Park

Updated 25 June 2015

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.

We undertook a focused inspection of Sandhall Park on 26 March 2015. This inspection was completed to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection 30 October 2014 had been made. We inspected the service against three of the five questions we ask about services: is the service safe, is the service caring and is the service well-led. This is because the service was not meeting legal requirements in relation to these three questions and we had issued enforcement actions.

The inspection was undertaken by two adult social care inspectors over the duration of one day.

Before our inspection we reviewed the information we held about the service, this included the provider’s action plan, which set out the action they would take to meet legal requirements. We also spoke with the local authority commissioning team and safeguarding team.

At the visit to the service we spoke with three people who lived there, five visitors, three members of staff, the deputy manager and the registered manager. During the visit to the service we looked at staff duty rotas, staff training records, three staff personnel files and quality assurance documents, which included audits and minutes of meetings. We also used the Short Observational Framework for Inspection (SOFI) to observe the care and support provided to people in the dining room at lunch time. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Updated 25 June 2015

The inspection took place on the 26 January 2015. The inspection was unannounced. At the last inspection the service was fully compliant with the regulations we looked at.

Sandhall Park is registered to provide accommodation and care for up to 50 older people. The service is a purpose built, single storey care home with car parking to the side and rear of the property. There were 48 people living at the home at the time of our inspection, some of whom had dementia care needs.

The home has a registered manager. 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.

During our inspection we identified 13 breaches in the Health and Social Care Act. This included care and welfare, safety and suitability of premises, safeguarding people from abuse, cleanliness and infection control, management of medicines, meeting nutritional needs, respecting and involving service users, complaints, consent to care and treatment, staffing, requirements relating to workers, supporting workers and assessing and monitoring the quality of service provision. These ranged from minor to major concerns. You can see what action we have told the provider to take at the back of the full version of the report.

We found that people were not always kept safe. Staffing numbers were insufficient and this was impacting on the care and support which people received. Not all people felt safe or confident in raising issues around their safety.

Risks were not always appropriately managed. Although accidents and incidents were recorded they were not analysed to prevent re-occurrence. A high number of falls were happening and the registered manager had not taken action to try to prevent them.

Recruitment practices did not follow company procedures and appropriate checks were not always completed.

Medication systems required review. Medication was not appropriately recorded and it was not clear if medicines were being given as prescribed.

Some of the maintenance checks were not up to date and we found some unpleasant odours in parts of the home. A major programme of redecoration was underway.

Staff did not always receive induction, training or supervision to support them in their roles. Training was not up to date and from our observations the quality of the training needs to be considered.

There was no dementia care model and little evidence to suggest that current guidance or research was being considered or that staff had the knowledge, skills or experience to provide safe, effective care for people.

Consent was not always gained and staff demonstrated little or no understanding of the Mental Capacity Act 2005. There was little evidence to demonstrate that people were involved in discussions regarding their care or treatment.

Staff did not demonstrate appropriate skills or knowledge when supporting people with distressed or anxious behaviours. This meant that people’s safety could be compromised.

The dining experience for people was poor with little in terms of choice. Mealtimes were task based rather than social opportunities for people and staff failed to respond to people’s requests.

The adaptation and design of the premises was not suitable for people with dementia care needs.

A major programme of redecoration and refurbishment was taking place.

People did not always receive appropriate care which met their needs. Care was task based and we observed examples where staff failed to respond appropriately to people’s requests for help.

People’s privacy and dignity was not maintained and people were not treated with respect. There was little evidence to demonstrate that people were offered choice.

People had their needs assessed and care records were available. Some of these records were not up to date and did not reflect people’s individual needs.

Social activities did not take into account people’s likes, dislikes and preferences. There was very little in terms of meaningful activity or social stimulation available.

The complaints procedure was not displayed and people told us they were not clear of who to complain to. When people raised concerns they were not responded to appropriately.

Some people did not know who the registered manager was. The home was not well managed and staff were not displaying appropriate values and behaviours.

Quality monitoring systems were ineffective and did not bring about change and improvement.