Inspection on 16/07/07 for Stafford Hall Care Centre

This inspection was carried out on 16th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Stafford Hall Care Centre 23/08/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stafford Hall Care Centre 138/140 Thundersley Park Road Benfleet Essex SS7 1EN Lead Inspector Sarah Buckle Unannounced Inspection 16th July 2007 08:00 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 Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 2 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. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stafford Hall Care Centre Address 138/140 Thundersley Park Road Benfleet Essex SS7 1EN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01268 792727 01268 795932 stafford.hall@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc Mrs Sharon Coral Maguire Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2006 Brief Description of the Service: Stafford Hall is a two storey building situated in South Benfleet and is registered to provide care and accommodation for up to forty people. The original property has been considerably extended over the years to provide the current level of facilities and accommodation. There are single and double bedrooms on the ground and first floors. There are two main communal areas, one is used as a lounge and the other as a dining room. In addition there is a small quiet lounge area that doubles as a visitors room. There is space for parking at the front of the property. The first floor is accessed via a passenger lift. Transport is required to access local facilities and amenities. The current fees at Stafford Hall are £367.15 per week for a local authority room, £502.00 for a private single room and £650.50 for a premier room. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine key inspection. A site visit was carried out to the service on 16th July 2007 by two inspectors and lasted eight and a half hours. During the course of the site visit a tour of the premises was undertaken, residents and relatives were spoken with, as were members of staff and visiting professionals. Residents and staff members were observed and relevant documents and records were examined. The manager at the home was involved in the inspection and feedback was given at the end of the day. Surveys were sent to residents, relatives, health care professionals and staff members. The information contained within those surveys completed and returned to the Commission will be reflected within the body of this report. The manager also completed an Annual Quality Assurance Assessment and returned this to the Commission. What the service does well: The initial assessment procedure within the home is well managed and residents are re-assessed each time they return to the home after an absence (such as a hospital stay). Information about the service provided is available for residents and their relatives or representatives. The complaints procedure is available to residents and relatives and both concerns and compliments are well recorded. One relative survey returned to the Commission stated, “Under very difficult circumstances the staff at the care home cope really well with the residents. They seem to run a happy home and there is a good atmosphere there. The rooms are nice and clean and the food is good”. A second relative stated, “Generally very pleased with the care my mother receives. She seems to be happy (at the home) and has put on weight!” One resident commented, “I would like to stay here. I’m happy here. Staff treat me very well. Very good to me” The staff team within the home are thought of highly. One relative stated “…..The staff are always friendly and cheerful and make us feel welcome no matter what time of day we visit. We are usually given a progress report on my mother without having to ask for this”, a second relative stated, “They love and care and are very friendly”. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care planning system within the home is good, however, it would benefit from more specific detail and the recording of changes in the needs of residents. The home would benefit from a greater staff quota. One relative stated in relation to this, “Calls of other residents for assistance are sometimes slowly answered as many cannot move around on their own”. A second stated that the home would improve by having “More staff around the day room. Enabling there (to be) always one in the room at all times to be able (to deal with) any incident as it occurs”. A further relative comment stated, “At times they do seem to be short staffed especially at weekends but they do not let the residents suffer. I know my mother gets confused, but she is much happier when the staff are familiar to her, so having agency staff is sometimes difficult, but I was told they were trying to use them less often. The staff are always kind and caring”. The activities within the home could be improved to ensure that the identified interests and needs of residents are met. The controlled drug cupboard was located on a stud rather than a solid wall and therefore needs to be moved to be in line with regulation. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 7 ‘As and when’ medication protocols were not in evidence during the inspection. These are important as they outline the specific circumstances in which PRN medication should be offered or administered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are not made until an appropriate needs assessment has been undertaken. EVIDENCE: Two care plans were examined in relation to initial assessment. The pre admission assessments were thorough documents, which identified the support needs of the resident and the way in which these would be met by the home. The assessment included a detailed ‘assessment of needs’, alongside assessments in manual handling, risk of falls, nutrition, pressure ulcers, continence and mental status. A tool to indicate the level of dependency of the resident was also part of the assessment. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 10 It was positive to note that new pre-admission assessments were completed for one resident each time they returned to the home having been in hospital and that the assessments were reviewed regularly. During the site visit to this service, it was positive to note that service user guides were available in resident’s bedrooms. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each individual within the home has a care plan, however, these do not consistently contain enough specific information. The health needs of residents are monitored and appropriate action taken as required. The medication procedures within the home are well managed. EVIDENCE: Two care plans were examined in detail. The first of these had clear and thorough support plans in place, which related to the needs identified in the pre-admission assessment. For example the support plan regarding mobilising stated ‘ensure (the resident) always has their frame close at hand; observe (the resident) when (they) mobilise; give a guiding hand when (they) stand to walk; long distances require a wheelchair; ensure it is in good working order; (the resident) can express (their) wishes well; can transfer from toilet and chair with a guiding hand only; staff to give clear instructions to stand’ etc. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 12 The support plan in relation to personal care details what the resident is able to do and what they require support to achieve. The support plan regarding nutritional needs stated that the resident was not currently eating any solid foods at their own request. Instead they were prescribed with meal supplements. The plan said that a daily nutritional sheet should be completed for the resident, however there was no evidence of this being completed during the 24-hour period that they had been within the home. The resident’s pre-admission assessment stated that they ‘appear very depressed’, however there was no support plan devised in relation to how this presented itself, or how it would be managed by the home. The second care plan examined contained a risk assessment regarding transferring using a hoist and a sling. The information contained within this was not specific enough i.e. it stated ‘Staff to follow hoisting procedure and communicate with (the resident)’, the risk assessment regarding bathing was also unspecific, stating as its action to minimise risk ‘ manual handling training, follow bathing procedures, all new and temporary staff to be made aware’. Care plans were in place for all identified needs and these were in the main part clear i.e. the plan regarding activities stated that the resident likes dominoes, listening to music, staff to find the time to sit and chat with (the resident), has own TV and will ask when wants it turned on, likes wildlife and has a bird table outside of room. The care plan detailed that the resident choose to remain in their room, feeding and watching the birds. Changes in need were recorded on the care plans and some were discontinued, as they were no longer relevant. The care plan regarding pressure sores did not adequately reflect the residents changing needs. For example, on 16/02/07 the resident was considered to be at risk of pressure sores and a plan was put in place to manage this. On 20/02/07 there is a new care plan devised as the resident has a grade two pressure sore. On 09/04/07 the care plan states ‘clear’, however, on 10/05/07 the district nurse requested two hourly turns and that the resident should get up for meals and then return to bed, and on 29/06/07 it states ‘On discharge from hospital (the resident) continues to require nurse visits as (they) still have their pressure sore’. A further care plan is in place for pressure sores, which states, ‘air flow mattress in good order, movement day and night, communicate with (the resident), observe skin, district nurse if concern’. The turn charts for this resident were examined and did not contain enough specific information. They stated ‘made comfortable and turned regularly’ but did not break this down into times, or positions turned from and to. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 13 Daily notes were well completed and demonstrated clear awareness of the needs of the resident. All concerns were recorded regarding when the resident was not eating or drinking or refusing to be turned. However, on 03/07/07 they record a grade two pressure sore on the residents elbow. This is not reflected in the care plan. Neither of the pressure sores were recorded on the body map within the care plan. The turn charts of a further resident with pressure sores were examined and these were completed in a specific manner, detailing the time of the turn and from either left to right or vice versa. Further information was also contained within this, including when cream had been applied and when the person concerned had been up for a meal. There was evidence of interventions by the district nurse, GP or emergency services as required by the resident. There were also clear multi-disciplinary reviews contained within the file. There are four GP’s used by residents within the home and one staff member stated that these are all very good. She said that three had been called on the day of the site visit and all of these were coming out to visit the home. The medication procedures within the home were looked at. The medication is booked in appropriately. The morning round starts at 08:30 and usually ends at 09:45. On the day of the site visit the round was just finishing at 10:00. There were no omissions on the MAR sheets and these tallied with the medication in the blister packs. Inhalers were labelled, and boxes, bottle and inhalers were dated when started. The medication file contained a list of signatures for those people with responsibility for administering medication. The temperature in the medication storage area is monitored and there is an air conditioning unit in place. The medication fridge is locked. The controlled drugs were examined during the site visit and it was noted that the cupboard was attached to a partition rather than a solid wall. The controlled drugs register was examined and the amounts recorded tallied with the amount of drugs in the cupboard. There was no evidence contained within the medication file to demonstrate that ‘as and when’ (PRN) medication protocols were in place. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is aware of the need to support people to develop their social and emotional skills, however, this process could be improved. People living at the home are given the opportunity to take part in activities; however, these are not necessarily geared towards the specific needs and interests of the individual. Food is of a satisfactory quality and meets the dietary needs of the residents. EVIDENCE: There are two activities coordinators employed at the home. During the site visit, the activities timetable for the week was seen being formulated and this included 1:1 time with residents and bingo. The activities coordinator spoken with stated that they had completed training in dementia and that they mainly focused on 1:1 work, such as reading, colouring and doing nails. Activities records were seen, but these did not reflect the needs of specific residents. For example, one resident had listed their interests as walking, swimming and walking the dog. There were seven activity entries for this Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 15 resident in July, however, they were not related to these interests but stated “The resident wanted to stay in her room when I went to take her – she seemed to be asleep”. The resident did make pom-poms, play bingo, watch lavender bags being made, attend a resident meeting and have their nails done. A second resident had eight activities recorded for July, but these included being ‘chatted to whilst being fed’. A further resident had interests listed as ballroom and Latin American dancing and their six activity entries were concerned with ‘chatting whilst assisting with food’. One of the resident surveys completed stated that there are always activities available within the home and they commented “I get a newspaper each day. I watch films I like on TV. I like to stay in my room”. Four surveys stated that there are usually activities provided. One comment stated “Jigsaws, singing, quizzes, bingo sometimes. I like Soul Watts when he comes in. Sing with the church service…” One resident did not complete this section however they did comment that there are quizzes, games, TV, sitting and chatting and I like the man that comes in. One further resident completed the survey and stated that there are sometimes activities arranged within the home. Two care staff spoken with stated that they did get involved in activities, however, this was more likely to be in the afternoon as there was more time. Observations made during the course of the site visit demonstrated that residents were not always able to exercise choice and control over their lives. They were seen to often be waiting for someone to attend to their needs. For example, one resident was noted to sit on a hard dining chair for the duration of the morning, through lunch and it was 14:00 before a staff member spoke with her and asked if she wanted to move. One resident was sitting on a hard dining chair and had to ask an inspector to move her, as there were no staff members available to do so. Later in the day the same resident had to ask an inspector to take her to the toilet, as there were no staff available to do so. The inspector went out of the lounge to find a care staff to attend to the resident. Two carers were giving out tea and biscuits to the residents, and when asked said that they would find someone else to attend to the resident. Meanwhile the resident was becoming increasingly uncomfortable. A carer did come to take her to the lavatory, however she brought a wheelchair with her, which was broken. The resident then had to wait while another wheelchair was found. The carer returned with a walking frame. However, the resident stated that she was unable to walk. At this point the carer called across the lounge to another carer and said ‘Is she walking?’ The resident was in some distress and a second wheelchair was found for her. All in all this process took over ten minutes. One resident review stated, “When I call for assistance sometimes I have to wait for staff” and “…no one really tells me why I have to wait”. One resident survey received by the Commission states that staff members are usually Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 16 available when needed. The comment says, “The staff are good, but there are not enough of them!”. A choice of tea and coffee and other fluids were offered in the morning and afternoon. Two of the residents surveys completed stated that they always like the meals at the home. One commented ‘I like my cooked breakfast’. Three residents surveys stated that they usually like the meals provide ay the home. One person commented that the lunchtime meals are too large. One person said that they sometimes like the food, stating that the food is “often cold, not well cooked. Food is very bland. Would like a regular cup of tea in the morning before breakfast time”. One resident survey did not complete this section, but stated that they think the meals are good. Nutritional records were examined and it was positive to note that these are audited every 24 hours. These were completed appropriately, however, some residen s with24 hour charts had their nutritional information recorded on these and some residents with meal replacement drinks had these recorded on the MAR sheet and not on the nutrition record. A simplified procedure for recording this information could be beneficial to the home. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns in safe and understanding environment. There is clear understanding of the need to safeguard vulnerable adults. EVIDENCE: The home was noted to have a complaints procedure and this was displayed appropriately. The complaints, concerns and compliments log was examined. The information contained within this was well recorded. Since January 2007 the home has received no complaints, five compliments and eleven concerns. The concerns logged were mainly related to issues such as a domestic opening a window and the room being cold, some laundry issues, noise from another resident and one lunchtime menu five residents said the meat was tough and the parsnips burnt. Six of the resident surveys returned to the Commission stated that they knew how to make a complaint. One was not completed. One comment stated, “I tell the office. I shout someone comes”. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 18 All seven of the relative surveys completed stated that they knew how to make a complaint about the care provided by the home if they needed to. It was positive to note that twenty-five staff members have completed training in challenging behaviour this year. The majority of staff members have also completed training in safeguarding vulnerable adults from abuse. One staff member spoken with said that they had not done the training yet, but they were able to express what the procedure within the home regarding this was. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an environment that is appropriate to the needs of the people who live there. It is a pleasant environment, which is in the main part well maintained. EVIDENCE: On the day of the site visit, a tour of the premises was carried out. Stafford Hall is in the main part a comfortable and homely environment, however, there are some areas within the home that are in need of refurbishment. Some of the skirting areas within the home were damaged and needed re-painting and one bedroom had cracked and peeling paint above the window. A number of fire doors were wedged open, however, the manager resolved this during the course of the site visit. A curtain pelmet was noted to be hanging down, and again this issue was resolved during the day. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 20 A number of commodes were without their lids and the majority of commodes seen were worn out and in need of replacement. Two hoists examined were dirty. All of the bedrooms within the home were nicely personalised with artefacts and photographs. The home was surface clean, but areas such as hoist slings need further attention to prevent the risk of cross infection. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 21 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home are generally satisfied that the care they receive meets their needs, however, there are times when they have to wait for staff support. The recruitment procedure is robust and there is a high level of importance placed on staff training. EVIDENCE: During the site visit to Stafford Hall, staff and residents were observed over a period of three hours. It was apparent that there were not enough staff members on duty to attend to the needs of all the residents. An example of one resident requesting assistance and having to wait for a staff member to be located has already been outlined previously in this report. The manager stated that the staff ratio is five care workers and one care team manager, however on the day of the site visit one care worker had taken a resident to hospital and there was one agency staff member on duty. A staff member spoken with stated that this makes the shift much more difficult to manage. They also stated that one extra carer would allow more time for interaction with residents. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 22 According to the AQAA, the care home currently has one member of staff with NVQ level 2 or above. However, eleven of the staff team are currently working towards this qualification. Two staff recruitment files were examined and these contained almost all of the specified information. One staff file for a new employee did not have a photograph and there was no evidence of a completed CRB check. However, there was evidence of a POVAFirst check and the manager stated that the employee was not working in an unsupervised capacity. Staff training is given a high priority within the home, and one staff member had completed dementia awareness on 13/02/07; basic first aid on the 19/01/07; POVA on the 21/02/07, basic food hygiene 06/11/06, challenging behaviour 28/03/07, manual handling on the 01/12/06; Franklins fire and safety on 22/05/07 and catheter training on 18/01/07. Twelve staff training files were examined and these demonstrated that there is a commitment to training the staff within the home. It was positive to note that some of the staff members are undertaking the eight-week dementia course, and the majority of the files examined had completed at least a oneday course in dementia. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 23 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. EVIDENCE: The manager at Stafford Hall completed the Registered Managers Award in August 2006. The office within the home is well organised and there are clear procedures in place regarding the running of the home. Pertinent information is clear and readily available. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 24 One staff member spoken with stated that Stafford Hall is ‘very well managed’ and that ‘everyone knows what they are doing’. A second staff member spoken with stated that the manager is open and inclusive in her approach. There is a supervision system in place, and one staff file examined had clear evidence of on-going support. The manager stated that there is a formal quality assurance system in place within the home and that she is currently actioning the outcomes of the audit. She said that a further quality audit is to be completed this year and that a copy of the findings will be forwarded to the Commission. The residents monies were looked at and the amounts available tallied with receipts. All of the entries regarding monies were doubled signed. The accident book was examined and all accidents are recorded appropriately and signed off. A number of health and safety certificates were examined and these were all in date. Fire risk assessments had been completed and there was a local fire plan in place. Fire drills were carried out regularly, however they did not always detail information regarding who had been involved in these. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 25 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. 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement Ensure that comprehensive and detailed care plans are devised for all residents. This is a repeat requirement with the previous timescale 01/12/06 not fully met. 2. OP12 16(2)(m) and (n) Ensure that all residents receive an appropriate programme of activities. This is a repeat requirement with the previous timescale 21/10/06 not fully met. 3. OP14 12(2) Ensure that residents are empowered to exercise real choice and control wherever possible about their lives and that they are appropriately supervised and supported at all times. This is a repeat requirement with the previous timescale 14/10/06 not met. 4. OP27 18(1)(a) Ensure that there are adequate DS0000067736.V343436.R01.S.doc Timescale for action 01/11/07 01/11/07 01/10/07 01/10/07 Page 27 Stafford Hall Care Centre Version 5.2 numbers of staff on duty at all times. This is a repeat requirement with the previous timescale 14/10/06 not met. 5. OP27 18(1)(a) Ensure that the deployment of staff within the home is suitable to meet resident’s needs. This is a repeat requirement with the previous timescale 14/10/06 not met. 01/10/07 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. Refer to Standard OP8 OP14 OP28 OP9 Good Practice Recommendations Turn charts should be consistently completed in line with individual resident’s requirements and their care plan. Interaction between staff and residents should be improved. Ensure that 50 of staff attain and achieve NVQ Level 2 or above. Ensure that the controlled drug cupboard is affixed to a solid wall in line with regulation. Stafford Hall Care Centre DS0000067736.V343436.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - 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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