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Inspection on 22/06/05 for Abbeyfield Stangrove Lodge

Also see our care home review for Abbeyfield Stangrove Lodge for more information

This inspection was carried out on 22nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

A new Activities Coordinator has been employed and the feedback from staff and residents was very positive about the activities she is providing. They said they wished she could come every day. The new dementia wing is now almost complete and looks fresh and welcoming. The Manager has obtained agreement for the carpets in the hallways of the existing wings to be replaced this year. More staff have begun work on their NVQ award and more staff training has been arranged. In particular the distance-learning course in Dementia was well received by staff.

What the care home could do better:

The Statement of Purpose requires some amendment to include the complaints procedure. The Service User Guide needs reviewing to ensure residents are receiving up to date information. It was discussed with the Assistant Manager that, whilst the care plans are detailed and informative, it would be beneficial if the information needed daily by staff to care for the residents was made more accessible. It was suggested that perhaps the care plan could be at the front of the file for easy reference. The residents should be asked to agree any changes made to the care plan. Some work is required in the communal bathrooms to make them safe for residents to use by covering exposed pipes and radiators. Residents would also benefit from decoration of these rooms to provide a more comfortable and inviting environment. The frames around the toilets need replacing as they currently present a risk of skin tears to the residents. These should be replaced with a style that can be fixed in position to avoid falls. One resident requested a non-slip mat for the bath. In order to ensure the temperature of residents medicines does not get too high it was recommended that a blind be fitted to the window in the medication room. The Medication Administration Records are still not alwaysbeing signed by the senior carer. Whilst this has improved it is still an issue that the Manager needs to address to ensure the safety of the residents. For the resident who is taking their own medication a risk assessment must be completed to ensure the protection of other residents from medicines being left unattended. Residents enjoy the activities available but would benefit from more of these. They also said they would like more opportunities to go out within the community and on day trips. Residents are not always having their weight monitored regularly. This is of particular concern for those at nutritional risk. It was noted that the home does not have seated scales and the staff said that this presents difficulties for some residents. It is recommended that seated scales be made available. For those residents who wish to have a key to their own bedroom this should be provided. The 2 residents who currently share a room should be consulted on their agreement to this and their decision recorded in the care plan.

CARE HOMES FOR OLDER PEOPLE Abbeyfield Stangrove Lodge Manor House Gardens Edenbridge Kent TN8 5EG Lead Inspector Jo Griffiths Unannounced 22 June 2005 10:00am nd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Abbeyfield Stangrove Lodge Address Manor House Gardens, Edenbridge Kent TN8 5EG 01732 864975 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Abbeyfield Medway Valley Society CRH Care Home 49 Category(ies) of OP Old age (27) registration, with number DE(E) Dementia - over 65 (22) of places Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Care of one service user is restricted to one person whose date of birth is 12/05/43 Date of last inspection 5/10/04 Brief Description of the Service: Stangrove Lodge is located in a quiet residential area within easy walking distance of local shops. All accommodation is on the ground floor. There are plenty of communal areas for residents to access and the majority of bedrooms are single. The gardens include an enclosed sensory garden, which is attractively laid out and well maintained with a paved area and seating, the garden is easily accessible from the home. 24 hour care and support is provided to older people, some of whom have Dementia. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by Regulatory Inspectors Jo Griffiths and Marion Weller. For the purpose of this report the people living at Stangrove lodge would prefer to be collectively referred to as the residents of the home. The Assistant Manager was present during the inspection and provided feedback on the achievements made toward the requirements from the previous inspection report. A tour of the building was undertaken and some records were inspected. 11 members of staff and 8 residents were spoken with as part of the inspection process. What the service does well: All residents have a full assessment of their needs and are assured these needs can be met before they move to the home. A detailed care plan is developed and kept up to date as these needs change. Residents are protected by safe procedures for administering their medication and are safeguarded against all forms of abuse by robust policy and staff training. Residents live in a homely environment and the majority have a single bedroom. They can furnish and decorate their room to their own tastes and they report that the staff are respectful of their privacy. The residents said they were happy with the décor of the home and the availability of space they can use in addition to their own room. There are plenty of toilet and bathroom facilities for residents to use that meets their individual needs. Residents can safely access the garden areas and were seen to enjoy the seated area in the sensory garden in the afternoon. There is also a fully equipped sensory room in the Dementia wing that residents can use. The residents speak very highly of the staff at Stangrove lodge. They said, “The staff are very pleasant” and “The carers here are very good”. The staff were observed carrying out their duties during the inspection and it was noted that they treated the residents with respect and demonstrated a good understanding of their needs. Staff spoken with said they enjoyed their jobs and felt supported by the management team. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 6 The residents are assured that they are protected by safe procedures for recruiting staff and they benefit from well-trained carers. The residents felt confident to approach the manager with any concerns they may have and the complaints log showed that these had been recorded and taken seriously. Residents said that they enjoyed the food. The menu showed that there are at least 2 choices at each mealtime and the cooks have a good understanding of catering for all needs. The residents particularly like the home baked birthday cakes. What has improved since the last inspection? What they could do better: The Statement of Purpose requires some amendment to include the complaints procedure. The Service User Guide needs reviewing to ensure residents are receiving up to date information. It was discussed with the Assistant Manager that, whilst the care plans are detailed and informative, it would be beneficial if the information needed daily by staff to care for the residents was made more accessible. It was suggested that perhaps the care plan could be at the front of the file for easy reference. The residents should be asked to agree any changes made to the care plan. Some work is required in the communal bathrooms to make them safe for residents to use by covering exposed pipes and radiators. Residents would also benefit from decoration of these rooms to provide a more comfortable and inviting environment. The frames around the toilets need replacing as they currently present a risk of skin tears to the residents. These should be replaced with a style that can be fixed in position to avoid falls. One resident requested a non-slip mat for the bath. In order to ensure the temperature of residents medicines does not get too high it was recommended that a blind be fitted to the window in the medication room. The Medication Administration Records are still not always Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 7 being signed by the senior carer. Whilst this has improved it is still an issue that the Manager needs to address to ensure the safety of the residents. For the resident who is taking their own medication a risk assessment must be completed to ensure the protection of other residents from medicines being left unattended. Residents enjoy the activities available but would benefit from more of these. They also said they would like more opportunities to go out within the community and on day trips. Residents are not always having their weight monitored regularly. This is of particular concern for those at nutritional risk. It was noted that the home does not have seated scales and the staff said that this presents difficulties for some residents. It is recommended that seated scales be made available. For those residents who wish to have a key to their own bedroom this should be provided. The 2 residents who currently share a room should be consulted on their agreement to this and their decision recorded in the care plan. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, Prospective residents will benefit from further review of the Statement of Purpose and Service User Guide to ensure they receive accurate information about the home. Residents have a full assessment of their needs and are issued with a contract for care at the home only if their needs can be met. EVIDENCE: Residents and other interested parties have access to the homes Statement of Purpose. This document has been recently updated and is well presented, but requires further amendment to include details of the homes complaints procedure and the policy on emergency admissions to the home. The Service User Guide contains the information residents will need about the home. It requires updating to ensure this is accurate, the Assistant Manager said that this was in hand. An example of a residents contract with the home was seen. This outlines the terms and conditions, provision of accommodation and fees. The Assistant Manager said that all contracts are signed by either the resident or their representative. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 10 All residents have a full assessment of their needs before moving into Stangrove Lodge. A member of the senior team carries out the assessment that covers all aspects of personal, health, emotional, social and spiritual needs. Examples of assessments seen showed how the information is used to formulate the care plan. Residents expressed their satisfaction with the care they are receiving and their confidence in the ability of the staff to meet their needs. The majority of staff have undertaken specialist training in the care of people with dementia. Evidence seen within care plans indicated that residents’ individual health needs were being met. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 10 Residents have a plan of care that meets their needs. They would benefit further from a review of these plans to ensure staff can easily access the information they need to support the residents. Residents are, on the whole, protected by safe medication procedures. Residents feel that they are treated with respect and that their rights are upheld. EVIDENCE: Each resident has a plan of care that is developed following extensive assessment of his or her needs. The residents files contain lots of information, however, this information could be presented in a more accessible way to allow carers easy access to the care plan. This would allow staff to focus on a consistent approach to the identified needs of the resident in the care plan. The care plans had been signed by the resident when they were first written, but there was no evidence to suggest that the residents are involved in the review and amendment of the plan. Care plans must provide traceable evidence of how changes in the needs of the residents are carried into the care plan and the recording documents. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 12 Resident’s medication is stored safely and securely. It is recommended, to maintain an appropriate temperature in the medication room, that a blind is fitted to the window. Controlled drugs are stored and recorded following safe procedures. Senior staff administer medication to residents from a locked trolley. The senior carer demonstrated good practice during the administration of the lunchtime medicines. All staff who deal with medicines have received approved training and there is a local policy for the home. One residents care plan indicated that they are being given their medication in their room by the staff and they are then taking it in their own time. A risk assessment must be completed to consider the risks to the individual and the other residents of leaving medication unattended. Medication records show that there are still some omissions in the signing of the Medication Administration Record (MAR). The Assistant Manager said that this had been addressed with senior staff following the previous inspection and that they would take this issue further. Residents spoke with high regard for the staff at Stangrove Lodge. Comments included “ The staff are very pleasant” and “The carers here are very good”. Residents were seen to be supported by the staff in a respectful manner that promotes their dignity. They can choose to have a personal telephone in their bedroom or can use the homes cordless phone in private. Staff spoken with were clearly aware of the need and ways to promote privacy and maintain dignity of the residents whist caring for them. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Residents enjoy the activities available but would benefit from increased frequency and choice. They do not have the opportunities to maintain contact with the local community as they would wish to, however visitors to the home are always welcomed. Residents receive a balanced diet and they are happy with the choice and quality of the meals. EVIDENCE: The need for more activities highlighted on previous inspection reports has still not been fully met. It was noted that some improvement had been made with the introduction of an activities coordinator, who provides activities in the Dementia unit twice a week. These sessions are greatly enjoyed both by the service users who attend and the staff who are involved in them. Residents from other areas of the home however rarely join in. When asked, they said they would prefer for activities to be provided in their own lounge. There is also a team of volunteers that visit the home for an hour once a week. The programme of daily activities for residents, advertised on the homes notice boards, could not be evidenced as having been consistently provided by the staff in the homes activities record. Lack of planning and provision of the displayed activities could prove frustrating and disappointing for residents who Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 14 have expectations of attending a particular event, which is then found to be unavailable. Through conversation with staff members it was evident that a degree of concern exists around them having available time and the expertise to deliver appropriate age related activities of a truly meaningful nature. The home has a well-equipped sensory room and materials for arts and crafts and residents would benefit from more opportunities to use this with staff support. Both residents and staff commented that not enough community activities and trips out take place. Most residents rely on relatives to take them out. Residents said they can receive visitors when they wish to and can see them in their own rooms, a communal area or a private room. Visitors came and went from the home throughout the day and were welcomed warmly. A church service is provided in the home each week and this is popular with the majority of residents. Residents can have the newspaper of their choice delivered. Residents said they enjoy the meals and are happy with the choices available. The choices for the day are offered to residents in the mornings and orders taken. The food served at lunchtime was well presented and looked appetising. Time was spent with the Cooks who described how a four-week menu is planned. This has recently been reviewed and is waiting for Management approval. The Cooks demonstrated a clear understanding of the needs of people with special dietary requirements and how to plan a balanced menu. On a daily basis the Cooks talk with the residents about their enjoyment of the meals and any complaints. Residents said that when it is their birthday the Cooks would bake a special birthday cake. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents are protected from abuse and are aware of how to make a complaint. Complaints are responded to efficiently. EVIDENCE: The home holds a record of all complaints received. There has been 1 complaint made to the Manager since the previous inspection in October 2004. This complaint related to communication with relatives and was resolved and responded to satisfactorily. There is a clear complaints procedure for the home and this needs to be included in the Statement of Purpose and Service User Guide to ensure it is accessible to all residents, relatives and visitors. Residents spoken with knew who to talk to if they had any concerns. Abbeyfield have a policy on Adult protection. Some staff have received training in this area and the Assistant Manager evidenced that further training for the remaining staff had been arranged. Staff are made aware of Adult Protection procedures during their induction. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Residents are accommodated in comfortable bedrooms that meet their needs and have access to well maintained and clean communal areas and gardens. They would benefit from refurbishment of the bathrooms and toilets to ensure their comfort and safety. Residents do not have suitable specialist equipment to meet their mobility needs. EVIDENCE: The home presents a homely and relaxed feel. All areas are well maintained and clean. There was a slight odour in the hallway of one unit and the Assistant Manager undertook to arrange a full carpet clean in that area. There has been agreement by the society for the carpets in the hallways to be replaced this year. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 17 The home is divided into 3 units, 1 of which specialises in the care of people with Dementia. The Dementia unit is secure for the residents with keypad access for staff. All units in the home have a lounge, dining room and sufficient bathroom and toilets. There is access to secure gardens, including a beautifully laid out sensory garden, from each unit and plenty of space for people to wander. Most residents have a single bedroom. There are 2 shared bedrooms and at present only one is being used as a double. The staff report that the 2 residents who are sharing are happy to do so. However, it is recommended that their agreement to share be recorded within their care plan and should a single room become available they should be offered this. Pictures are displayed on the doors of the bedrooms in the Dementia wing. This is to aid residents in their orientation. All the bedrooms viewed were individually decorated and fully furnished. Residents have brought personal items with them into the home and this gave their bedrooms a homely feel. 2 bedrooms have ensuite facilities. Not all the bedrooms have a key for residents who may wish to lock their room. One bedroom has an external bolt that must be removed as the resident who fitted this is no longer at the home and it may present a risk to the current resident. The home is generally decorated to a high standard and the handyman ensures a rolling programme of decoration takes place. The bathrooms and toilets are in need of some refurbishment. There are uncovered radiators situated behind the toilets and exposed pipe work and this could present a risk to residents. The bathrooms could be improved with some redecoration to provide a more homely feel. Residents reported that they have experienced no problems with the laundry service. The procedures in the home for managing soiled laundry and clinical waste ensure the protection of residents against cross infection. However, it was discussed with the Assistant Manager the need to remove communal soap from the bathroom. Each toilet has a frame around it to aid mobility. These frames are in a poor condition and present a risk of skin tears to residents. New frames should be purchased in consultation with an occupational therapist and these must be fixed to the floor or wall to minimise the risk of falls to residents. There are sufficient assisted baths and showers around the home. One resident requested a non-slip mat for use in the bath. It is recommended that seated scales be purchased to allow for more consistent monitoring of weight for those who have difficulty standing. On the day of the inspection the weather was very hot and staff were seen to make every effort to ensure the residents were kept cool, by opening windows and positioning fans. It was noted that the kitchen was extremely hot and the Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 18 fan was not working properly. This was discussed with the Assistant Manager who said they would provide free stand fans to ensure the comfort of staff working in the kitchen. The home are currently developing a new Dementia wing. This has sufficient facilities for residents and is decorated to a high standard. There was some concern raised by staff about the amount of communal space available in the lounge diner and this will be discussed with the owners. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Residents are protected by safe procedures for recruiting staff. They are supported by sufficient numbers of competent and well-trained staff. EVIDENCE: Sufficient staff were on duty to support the residents and the rota evidenced that this was consistent practice. The staff observed on duty demonstrated competence in their role and an understanding of the needs of the residents. A group of staff were spoken with and they described the range of training they had undertaken. The training records were inspected and these showed that training is well planned and delivered in this home. Some staff said they had completed or were working toward the NVQ although this standard was not fully inspected on this occasion. The staff spoken with all expressed their enjoyment of their job. The Assistant Manager described the procedure for staff induction. This involves shadowing a more senior carer and undertaking a 6-week induction that encompasses the TOPSS standards. In addition to the induction staff complete a range of courses including Moving and handling, fire safety, POVA and a 12-week course in dementia. The home has its own training facilities. Staff files were sampled and these contained the required documents to ensure the safety of residents. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 20 Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36, 38 Residents’ benefit from a well managed home that is run by a qualified, competent and approachable Manager. Residents are protected by safe procedures for managing their monies and their welfare. The staff are well supported and supervised by the management team. EVIDENCE: The Manager of the home holds relevant qualifications in Management and is a registered nurse. Staff spoke highly of the Manager and the way in which the home is run. Residents spoken with said they were confident to approach the Manager with any concerns. Residents who wish to deposit their money to the home for safekeeping can do so. These monies are held securely and are accounted for correctly. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 22 Staff said they regularly meet with their supervisor and the Assistant Manager described the process for supervision of staff and appraisal. It was discussed with the Assistant Manager the benefits of a matrix to monitor the frequency of staff supervisions, and it was noted that this was in hand with the Manager. Risk assessments have been completed to ensure the safety of the residents. The areas that need further attention in terms of Health and safety were discussed with the Assistant Manager and these include a risk assessment for the resident who is taking their own medication and the review of infection control procedures to ensure communal soap is not used. As discussed under standard 25 the exposed pipe work and radiators require covering in the bathrooms and toilets. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 2 2 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 3 x 2 Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(2)(n) Requirement The registered person shall having regard to the size of the care home and number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of the service users, activities in relation to recreation, fitness and training. The registered person shall make arrangements for the recording, handling,safekeeping, safe administration and disposal of medicines received into the care home. In that, Accurate records of medication administered must be kept. A risk assessment must be completed for the resident who administers his own medication. The registered person shall review the Statement of Purpose to ensure that all items required under schedule 2 are included. The Service User Guide must Timescale for action 30th September 2005 This req is carried forward from the previous inspection. 2. OP9 13(2) 31st July 2005 The first part of this req is carried forward from the previous inspection 31st July 2005 3. OP1 4(c) 6(a) Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 25 4. OP25 OP38 13(4)(a) contain up to date information for residents. The registered person shall ensure that all parts of the home to which residents have access are, so far as reasonably practicable, free from hazards to their safety. In that, The pipes and radiators in the bathrooms and toilets must be covered. The registered person must make arrangements for the provision of fixed rails around the toilet and ensure they are in a good state of repair. Action plan to be submitted to CSCI 5. OP22 23(c)(n) Action plan to be submitted to CSCI RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP9 OP22 OP23 OP24 OP19 Good Practice Recommendations It is recommended that the care plans be made more accessible to staff and that residents agree any changes within the plan. It is recommended that a blind be fitted to the window of the medication room. It is recommended that seated scales be made available for residents with mobility difficulties. It is recommended that residents who share a bedroom give their consent to this and that this is recorded in the care plan. It is recommended that residents are offered keys to their bedroom. It is recommended that the bathrooms be decorated in a way that provides a homely feel for the residents. Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection The Oast Hermitage Lane Maidstone Kent, ME20 6QJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbeyfield Stangrove Lodge H56-H06 S24017 Abbeyfield Stangrove Lodge V217627 270405 Stage 4.doc Version 1.20 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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