Archived: Sandgate Manor

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.

People we spoke with were happy living at Sandgate Manor. They were complimentary of the care provided and the staff who supported them. One person told us 'I am fine, I have no concerns at all'. Other comments included 'I feel able to speak to the staff and they listen to me' and 'I can't think of anything I don't like here'. People felt involved in the planning of their care and there was opportunity to discuss this with staff.

We looked at people's care plans and found they had been reviewed when needed. People had consented to care and treatment where able to do so and we found evidence of best interest meetings where they could not.

We looked at the management and administration of medicines. People received the medicine they required when they needed it. However, we have made some comments to the provider about the storage of medicines that need to be addressed.

Staff recruitment records confirmed that appropriate processes had been followed. Checks made sure that staff employed were suitable to work with vulnerable people.

The quality of care was monitored by the manager and provider. Records showed that safety assessments were in place.

People we spoke with were happy living at Sandgate Manor and spoke positively about the staff. Comments people made included 'I have much more independence here' and 'The staff are great, I have never had cause for concern'.

People told us that they felt involved in decisions about their care and support and were given choices about their daily routines, such as when to get up and go to bed, what to eat and what to do each day. People had opportunities to choose and take part in activities and events which helped with daily living skills and offered access to the community.

People said they were happy with their bedrooms and that they were kept clean and tidy. Other people told us that their accommodation offered the opportunity for independent living, safe in the knowledge that staff were at hand if needed.

All of the people we spoke with told us that they were satisfied with the care and support provided. One person commented 'I am always given the opportunity to discuss my care plan, I am involved in my care'. We saw that staff were supportive and considerate of people's different needs and knew how to communicate with them. People were offered choices and we saw that their dignity and independence was respected.