The inspection took place on the 3 and 7 August 2017. The inspection was unannounced on the first day, and announced on the second. At the last inspection there were no breaches of Regulations identified.Sandiway Manor is located five miles from Northwich in Cheshire and is run by a charitable organisation. It provides accommodation and personal care to older people and can accommodate up to 28 people. At the time of the inspection there were 19 people living at the service.
There was a registered manager in post within the service. 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 this inspection we identified that medication was not always dispensed safely, or as prescribed. We found issues relating to monitoring the quantity of medication being stored, which impacted upon the efficacy of audit systems.
Audit systems were not always effective. For example they had failed to identify and address issues relating to medication systems. Health and safety audits had not identified where radiators had been exposed in communal areas, and care plan audits had failed to address known issues. For example, whilst it had been identified that staff were not completing malnutrition risk assessments, this had continued to be an issue.
The registered provider’s quality monitoring of the service was not robust enough to identify required areas of improvement within the service. Where issues were identified, action was not taken in a timely manner to address these. Quality monitoring audits did not give consideration to the requirements of the Health and Social Care Act 2008, and therefore were not able to identify areas that needed improvement.
The registered provider had not given due consideration to the Data Protection Act 1998 in determining how long to store people’s personal information for. We found boxes of records being stored which the registered manager told us were being kept for 50 years before being destroyed.
You can see what action we told the provider to take at the back of the full version of the report.
The service supported some people living with dementia, however the registered provider had not made any suitable adaptations to the environment to support and promote wellbeing. The registered manager told us that a lighting specialist was due to be consulted to look at ways of improving people’s visual perception. However other options such as the use of colour schemes, or placing objects of interest about the service had not been considered. We have made a recommendation to the registered provider around this.
People are supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However the policies and systems in the service did not always support practice that was in line with the requirements of the Mental Capacity Act 2005. Mental capacity assessments and best interest decisions were not always being made where required. We have made a recommendation to the registered provider around this.
There were sufficient numbers of staff in post to meet people’s needs. There was a staffing tool in place which enabled the registered manager to determine the number of staff required depending upon occupancy levels and people’s dependency.
Recruitment processes were robust and ensured that staff were of suitable character to work with vulnerable people. New staff had been subject to a check by the disclosure and barring service, and had been required to provide references from their most recent previous employer.
People were protected from the risk of abuse. Staff had completed training in safeguarding vulnerable adults and were aware of how to report their concerns to the local authority.
Where people had been identified at being at risk of deteriorating physical or mental health, or a pattern had emerged from monitoring of accidents and incidents, they had been supported to access health care professionals. This helped to ensure people’s wellbeing was maintained.
People commented positively on the food that was available. During meal times they received the required support to ensure they had enough to eat and drink. Kitchen staff were aware of those people who required a special diet which helped ensure people received meals that were appropriate for their needs. This helped protect people from the risk of malnutrition.
Staff were kind and caring towards people. They offered support where it was needed, and were patient when providing support. They worked to ensure people’s privacy and dignity was maintained by knocking on doors prior to entering, and ensuring doors were closed whilst supporting with personal care tasks.
Positive relationships had been developed between people and staff which was evidenced by the flow of conversation, and the laughter that was heard within the service. People’s family members commented that they were made to feel welcome when they visited the service, which enabled them to spend time with their relatives.
People each had a personalised care record which included information about their support needs, and what staff needed to do to support them. These were reviewed to ensure they were kept up-to-date; however we identified some issues around monitoring of people’s risk of malnutrition. Information about people’s life histories was also included, which provided staff with valuable information around getting to know the people they supported.
There was a complaints process in place which was on display in the reception area of the service. Whilst no recent complaints had been made the registered manager was aware of the process that should be followed.
The registered provider had completed a survey of people’s experience of the service. This showed that a majority of people were ‘very satisfied’ or ‘satisfied’ with the service that was being provided to them. This process enabled the registered provider to ascertain any issues people may have, so they could act upon their concerns.