Archived: Sandgate Manor

Updated 1 June 2016

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 on 15 & 16 March 2016 and was unannounced. The inspection team comprised of two inspectors.

Prior to the inspection we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. This was completed and returned to us. We looked at the information provided in the PIR and used this to help inform our inspection. We reviewed the records we held about the service, including the details of any safeguarding events and statutory notifications sent by the provider. Statutory notifications are reports of events that the provider is required by law to inform us about.

At inspection we met and spoke with many of the people who lived in the service and observed how they interacted with each other and with staff. We observed staff carrying out their duties and how they communicated and conversed with each other and the people they supported.

We met and spoke with ten people and three visiting relatives. Not everyone we met and spoke with who lived in the service was able to speak with us so we used the Short Observational Framework for Inspection (SOFI); SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also spoke with the Provider, registered manager, two deputy managers, a team leader and three other staff. After the inspection we spoke with four health professionals who visit the service who raised no concerns.

We looked at four people’s care and health plans and associated risk assessments. We looked at medicine management, and a range of operational records including three staff recruitment records, records of staff meetings, residents meetings, staff training and supervision records, staff rotas, accident and incident reports, servicing and maintenance records and quality assurance surveys and audits.

Updated 1 June 2016

The inspection was unannounced and took place on 15 & 16 March 2016. This service provides accommodation and care for up to 25 people with complex physical care needs. At the time of inspection there were 21 people living at the service. There were 19 people living in the main house with accommodation arranged over two floors a shaft lift provided access to the first floor. There are also three lodges in the grounds. These can accommodate up to two people in each lodge but are currently used as single accommodation there were two people living in two separate lodges at inspection and one lodge was vacant. The home is located in a residential area of Sandgate. It is within walking distance of local amenities, shops and public transport. The main town of Folkestone is nearby and can be accessed by car or public transport.

This service had a registered manager in post. 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.

This service was last inspected on 13 November 2014, at that time it was assessed as ‘requires improvement’ owing to shortfalls in: staff training records, inadequate audit processes were in place which were not effective, complaints were also not shown to be managed effectively. Since then the provider and registered manager along with senior staff have made improvements to these areas and the outstanding requirements for these shortfalls has now been met.

This inspection, however, highlighted that new quality monitoring processes are still to embed and that some minor shortfalls in operational records maintained by the service have yet to be reviewed through the quality monitoring checks made. For example some recruitment information obtained during the recruitment process had been discarded, regular fire drills were happening but monitoring of how many drills individual staff attended was not in place.

Staff were trained to meet people’s needs and had opportunities to discuss their performance and work related issues during one to one meetings with their supervisor. People were safe and protected from harm because there were enough staff available to support them in the service and when out in the community, this was confirmed by people and staff and the rota reflected the staff on duty at inspection.

Staff felt listened to, supported and well informed. Several staff meetings were held each year which staff thought were enough but said the frequency of these could be increased if important information or issues needed to be discussed with the staff team.

People were encouraged by staff to make everyday decisions for themselves. Staff understood and were working to the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a framework for acting and making decisions on behalf of people who lack mental capacity to make particular decisions for themselves. People and relatives told us they found staff approachable and felt confident of raising concerns if they had them. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood when an application should be made and the service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were treated with kindness and respect; they said their needs were attended to by staff when and if they required it. People respected each other’s privacy. People were supported to maintain links with the important people in their lives and relatives told us they were always consulted and kept informed of important changes.

People were well matched, they liked each other’s company and being of similar ages many had shared interests. They told us they were happy there. Most had personal support hours allocated to them and chose how they utilised these hours to do the activities they wanted to do. Staff listened to what people had to say. Staff said they enjoyed working in the service and our observations showed that there was “a lot of laughter and a lot of fun”, within the service.

People told us they felt safe and liked the registered manager and all the staff that supported them. Relatives told us they had no concerns about the service and were satisfied with the overall standard of support provided. They felt confident in the quality of care and said they were kept fully informed by the staff and communication was good. Professionals we contacted commented positively about the service and raised no concerns.

People’s medicines were well managed by trained staff. Staff were able to demonstrate they could recognise, respond and report concerns about potential abuse. The premises were well maintained and all necessary checks tests and routine servicing of equipment and installations were carried out.

People ate a varied diet that took account of their personal food preferences. Their health and wellbeing was monitored by staff that supported them to access regular health appointments when needed. Staff understood people’s individual methods of communication and how they best received information.

People were supported to develop and maximise their potential for independence at a pace to suit themselves and that they were comfortable with. Staff were guided in the support they gave to people through the development of individualised plans of care and support; risks were appropriately assessed to ensure measures implemented kept people safe.

People and relatives were routinely asked to comment about the service and their views were analysed and action taken where improvements could be made. A new quality assurance system had been implemented that looked at the self-assessment of performance with different aspects of the service, shortfalls were identified and action plans with clear timescales implemented to ensure improvements were addressed.

We have made three recommendations:

We recommend that the provider replaces personal identity information removed from staff files.

We recommend that a record is made of informal meetings and discussions with staff to inform the overall appraisal of their performance.

We recommend that the provider monitors whether all staff are participating in a minimum of two fire drills annually in accordance with recommendations for staff contained in the Regulatory Reform (Fire Safety) Order 2005.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.