Inspection on 23/08/06 for Stafford Hall Care Centre

This inspection was carried out on 23rd August 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stafford Hall Care Centre 16/07/07

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 Michelle Love Key Unannounced Inspection 23rd August 2006 09:00 X10015.doc Version 1.40 Page 1 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.V309995.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.V309995.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 runwoodhomes.co.uk Runwood Homes Plc Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide accommodation to one person who is under the age of sixty-five (65) years and whose name is known to the Commission for Social Care Inspection. N/A Date of last inspection 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 homes pre inspection questionnaire was not forwarded to the Commission prior to the site visit. The acting manager was requested at the site visit to complete some elements and to forward the information. The range of fees charged to residents, were not recorded. The pre inspection questionnaire detailed additional charges to residents i.e. hairdressing, chiropody, newspapers and magazines and personal toiletries. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced `key site` visit was undertaken by Michelle Love, inspector, over a period of approximately 10 hours. At this site visit the inspector conducted the inspection with the acting manager. During the visit several residents, members of care staff and visiting professionals were also spoken with. As part of the process a number of records relating to individual residents and care staff were examined i.e. care plans, staff employment files, nutritional records, accident records etc. Additionally the homes medication systems were observed and records inspected. Following the site visit a number of surveys/letters were forwarded to a random sample of resident’s next of kin, requesting their views as to their member of families experience in the care home. It was disappointing to note that to date the Commission for Social Care Inspection has received no responses. Runwood Homes PLC purchased Stafford Hall in June 2006. The Commission for Social Care Inspection recognises that some records as set up by the previous registered provider, have either been mislaid or are very muddled and require time and effort to sort out. Prior to the site visit, the Commission for Social Care Inspection received an application by the registered provider to vary the homes registration (to admit 20 older people who have a dementia category). The application is currently, being processed by the Commission. In addition to the application, the registered provider will have to evidence that the premises is suitable, that there is a suitable programme of activities, that staffing levels are appropriate and that staff are trained in dementia, challenging behaviour and have up to date mandatory training. What the service does well: All residents are assessed prior to admission to ensure that the care home is the right place for them. The new admission format introduced by Runwood Homes PLC also includes formal assessments relating to manual handling, nutrition, continence and pressure areas. Despite a programme of redecoration/refurbishment, the home’s environment remains pleasant and homely and in general terms provides residents with a Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 6 safe place in which to live. The home is located within reasonable distance of all local amenities and facilities. What has improved since the last inspection? What they could do better: The Commission recognises that the new registered provider has implemented a new care plan format. The care plan format was seen to be appropriate, however care plan documentation was seen in most cases to lack detail and clarity. Additionally it was concerning to note that not all residents had a plan of care devised. It is essential that the homes care planning processes improve in line with regulatory requirements as detailed within the National Minimum Standards and Care Homes Regulations for Older People. It is pleasing to know that senior staff at Stafford Hall are to receive care planning training. It is hoped that this training will be cascaded to care staff in due course. Some improvement is required pertaining to staff recruitment, ensuring staff rosters/staffing levels are appropriate and that staff training is up to date and includes both mandatory and specialist training. Unfortunately on the day of the site visit it was evident that training records for staff were muddled and incomplete and it remains unclear as to what training has been undertaken and attained by some staff. It was concerning to note that despite some staff receiving training, staff lacked confidence and carried out unsafe and inappropriate care practices i.e. manual handling. The deployment of care staff within the home continues to need reviewing so as to meet the needs of residents. The registered provider must ensure that there are sufficient numbers of staff on duty at all times and that the home’s lounges are adequately staffed so as to ensure residents health and well being. It was disappointing to witness poor interaction between some members of staff and residents and a lack of care and understanding of individual residents needs. This is unacceptable and must be addressed as a matter of priority and urgency. The Commission for Social Care Inspection must be assured that resident’s who live at Stafford Hall, are supported by care staff, that they are valued and have their basic core values met. A programme of meaningful and stimulating activities must be provided to all residents residing at the care home, irrespective of their needs. If staff require Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 7 training in relation to activities this must be provided by the registered provider. Activities must cater for both those residents whose needs are complex i.e. lack motivation/have physical disabilities and constraints, and for those who are mentally alert and independent. 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. Stafford Hall Care Centre DS0000067736.V309995.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.V309995.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service Users Guide. Prospective residents are assessed prior to admission. EVIDENCE: Following the site visit a copy of the homes Statement of Purpose and Service Users Guide was forwarded to the Commission. On inspection of both documents these were observed to be satisfactory and in line with regulatory requirements. A revised copy of the homes Statement of Purpose has been received by the Commission pertaining to their application to vary the homes registration so as to admit, older people who have a formal diagnosis of dementia. Of three care files examined for the newest residents, all were noted to have been assessed prior to admission to the care home. The pre admission assessments did not evidence whether or not prospective residents and/or their representatives had an opportunity to visit Stafford Hall prior to admission. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care at this time. Stafford Hall Care Centre DS0000067736.V309995.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home has a system for recording individual resident’s needs, the care plans are not detailed or comprehensive. Risk assessments are not devised for all areas of assessed risk. Records relating to individual resident’s healthcare needs are not maintained. Residents are not always treated with respect and dignity. EVIDENCE: On inspection of five individual resident’s care files, only four plans of care were evident. Care files inspected did not include information pertaining to health, emotional, physical, personal and social care needs. Additionally care plans were observed to be inconsistently completed i.e. one care plan covered elements relating to nutrition, personal hygiene, constipation and mobility. Another care plan only made reference to falls, communication and nutrition. It is concerning that no further information was recorded relating to personal care/hygiene, mental health/behavioural issues, social and leisure, continence, pressure area care, medication etc. Information recorded did not always include in sufficient detail, the action which needs to be taken by care staff to ensure that individual resident’s needs Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 12 are met i.e. one care plan made reference to the resident having a poor appetite. No information was recorded pertaining to how care staff are to manage this aspect i.e. resident requires a soft diet/requires physical assistance from staff. Although the care plan format is new and includes formal assessments relating to manual handling, falls, mental health, continence and pressure ulcers, these were not completed within all files examined. Risk assessments were not devised for all areas of assessed risk e.g. the care plan for one resident detailed that they were at high risk of falls and had a limited/poor appetite. Only one risk assessment was recorded relating to the resident wishing to have their bedroom locked at night. It was of concern that turn charts for one resident were inconsistently completed. No care plan was devised for this resident and from discussions with a senior member of staff the inspector was advised that the reason for the inconsistently was as a result of the resident refusing to be turned at night and during the day they were sat in a chair. The turn charts recorded that the resident should be turned 3 hourly. Records highlighted the following: 7.8.06 the resident was turned at 11.00 a.m. and not again until 22.00, on 9.8.06 nothing was recorded after 06.00 a.m. and on 10.8.06 nothing recorded until 23.00. No information was detailed depicting as to whether or not the resident had been asked if they wished to be turned/or if they refused/or if they were transferred to a chair. Daily care records are written daily, however no entry is recorded after each shift. This is seen as poor practice and needs to be reviewed for the future. Some records were seen to be relatively detailed and informative whilst others lacked information relating to staff’s interventions and outcomes i.e. one resident’s records recorded that they had refused food on occasions and that they became unwell. No information was recorded relating to what staff intervention was provided i.e. was a GP contacted/consulted etc. It was very concerning to observe care staff within the home attempting to physically lift one resident and to not use a hoist for manual handling procedures. The visiting district nurse was observed to intervene and advised care staff that they must not manually lift any resident residing at the care home. Following this incident the hoist was used on the resident to ensure the residents safe transfer from their chair to a wheelchair. Care staff, were shown by the district nurse how to use the hoist. One of the carers advised the inspector that they were unsure how to use the hoist despite having received manual handling training. As a result of one resident’s bedroom carpet being cleaned, they were unable to be seen in private by the district nurse and interventions had to be provided within the main lounge area. This is seen as not good practice and the Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 13 resident’s dignity and right to privacy was not respected. The appointment was scheduled and appropriate measures should have been made to ensure that a private area was readily available. Additionally some members of staff were noted to enter residents’ bedrooms without knocking. The inspector observed that one resident’s catheter was not fitted appropriately, however this was dealt with by the district nurse at the time of her visit. The acting manager must ensure that care/senior staff receive training in this area. The homes medication storage systems were seen to be appropriate. It was positive to note that no omissions of staff signatures were observed on the homes medication administration records. The senior carer in charge of medication was advised that the current list of staff names/signatures and initials needs to be reviewed and updated. The inspector observed that medication administered to residents on the morning of the site visit was late (still being administered at 10.50 a.m.) and that the lunchtime medication was due soon after. The homes lunchtime medication was noted to be administered one hour later. The manager and senior staff must ensure that medication is administered promptly to residents and as close to the prescribed time as per the GP/Pharmacist’s instructions. It is evident that only having one Care Team Manager/Senior on duty to administer medication is problematic and insufficient. This needs to be reviewed for the future. Stafford Hall Care Centre DS0000067736.V309995.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 at least once during a 12 month period. 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 has an ‘in house’ programme of activities for residents. Residents receive a choice of meals throughout the day. EVIDENCE: The home has one activity co-ordinator for 25 hours per week (Monday to Friday). Records indicate that activities undertaken by residents include nail care/manicures, dominoes, draughts, arts and crafts, 1-1 sessions, bingo, flower arranging, table skittles and external entertainers. It is disappointing to note that although the homes location is relatively close to shops and cafés, residents do not access or participate within their local community. Careful consideration must be given by both the registered provider and activities coordinator to ensure that all residents benefit from a programme of meaningful activities and stimulation. This must include those residents who have limited communication, cognitive development and complex needs. From discussions with the activities co-ordinator, she appeared focussed, enthusiastic and committed to her role. The inspector was advised that she has devised some pictorial activity sheets, which she hopes she will get laminated and displayed on notice boards located within the home. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 15 General interaction between residents and some members of care staff was observed to be poor throughout the day. The lunchtime meal was observed to look appetising and plentiful. Residents were noted to have a choice of two main meals i.e. roast chicken/vegetables or fish cakes/vegetables. The majority of residents were not consulted as to whether or not they wished to have gravy on their meal and there was no tomato ketchup/parsley sauce available for the fish cakes. Dinning tables were fitted with tablecloths, however not all tables had condiments readily available and jugs of juice/water were not placed on tables to enable some residents to maintain their independence. Additionally throughout the day no jugs of juice were evident within the lounge areas. At both the morning/afternoon tea breaks it did not appear that residents were given a choice of drink and there appeared to be no cold drinks available. Residents were noted to be handed biscuits, and not given a choice. During the lunchtime meal two carers were noted to assist individual residents with their lunchtime meal. This was undertaken sensitively, however little verbal interaction took place between the care staff and the residents. During the meal one resident was observed to choke on her dessert of peaches and cream. No staff noticed that the resident was choking and the inspector had to intervene. Resident’s comments relating to the quality of food were mixed, with some positive and negative remarks. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure. No local protection of vulnerable adults procedures were available. EVIDENCE: The home was noted to have a complaints procedure, however this was not displayed due to the home being redecorated and refurbished. The acting manager advised the inspector, that since Runwood Homes PLC have owned Stafford Hall no complaints have been received. On the day of the site visit no local protection of vulnerable adults guidelines/local procedures could be located. The acting manager advised the inspector that existing staff training records are unclear and do not provide sufficient evidence as to who has attained/undertaken protection of vulnerable adults training and challenging behaviour training. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes environment is undergoing major redecoration and refurbishment. EVIDENCE: Runwood Homes PLC is the new registered provider of Stafford Hall. Since purchasing the property in June 2006, it is evident that the registered provider is devoting much time and effort to redecorate and refurbish the premises. On the day of the site visit the inspector noted that many areas of the home have been repainted, individual resident’s bedrooms have been re-carpeted, vanity sinks/cupboards replaced, curtains replaced/in the process of being fitted and a new call alarm system installed. Since the inspectors last visit to Stafford Hall, a decking area has been newly created to enable residents to access the garden safely. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 18 The homes laundry has been refitted with additional equipment (2x washing machines and 2x tumble dryers) and now has a `in` and `out` door for both clean and soiled laundry. This is seen to be a vast improvement compared to what was in place by the previous registered provider. On the day of the site visit several decorators/contractors were observed to be in the home. Some areas of the home were congested despite workers efforts to enable care staff to go about their routines and daily tasks. One health and safety issue was highlighted pertaining to one resident having a large armchair blocking their doorway/entrance, which was seen as a potential fire hazard. Additionally throughout the day relatively loud music was noted to be played by the contractors, and it was evident that some residents disliked the continuous noise. The Commission for Social Care Inspection is concerned that it was not notified as to the scale of redecorating/refurbishment to be undertaken by the registered providers or made aware of the impact this was to have on residents living at the care home and care staff providing care. Many staff members spoken with advised that the disruption at the home “has been a nightmare” and “ I’ll be glad when it is over”. It was unclear as to what consultation had taken place by the registered provider to residents and/or their representatives prior to works being carried out. During feedback to the acting manager and the registered provider’s contracts manager, neither was able to state as to whether or not this had actually been undertaken. Resident’s comments relating to `works` were mixed as some residents could see the positives, whilst others appeared unhappy and confused. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some gaps were observed in relation to staff recruitment records and staff induction. Staffing levels on occasions appear insufficient to meet existing residents needs. EVIDENCE: The inspector was advised that since the last inspection three members of staff have commenced employment at Stafford Hall. Some gaps were observed relating to one person’s employment history not being fully explored and only going back as far as March 2000. Additionally the completed application form was basic and poorly completed and did not include details of the applicant’s experience and qualifications. On two files no health/medical declaration was recorded and no photograph was evident. It was positive to note that interview questions and answers were available for two applicants. On inspection of three staff employment files, a record of induction was only available for one person. The acting manager has devised and implemented a staff induction pack. The acting manager was able to demonstrate an awareness and understanding of the `Skills for Care Induction Procedures`. The acting manager has also introduced an induction pack for those staff who `act up` in a senior role. The inspector was advised that current staffing levels are 1x care team manager and 4x care staff between 07.30 a.m. and 21.30 p.m. and during the night 1x care team manager and 2x care staff between 21.30 p.m. and 07.30 Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 20 a.m. The acting manager further advised that care team managers commence their duties 15 minutes earlier to enable a handover period. On inspection of three weeks staff rosters it was evident that on some occasions staffing levels have fallen below the above levels i.e. on 7.8.06 the staff roster indicated that only 3x care staff were on duty in the morning. Records detail that one member of staff was scheduled to complete training, however the staff roster did not detail who had replaced them. Also on 8.8.06 the staff roster detailed that only 3x care staff were on duty on the late shift etc. The agency staff roster was not fully completed on occasions and there was no evidence to indicate what measures had been undertaken by the senior in charge to address the staffing shortfall. The staff rosters indicated that there was no digression with night staffing levels. Should there be a shortfall of staffing levels in the future, the registered provider must notify the Commission on a Regulation 37 Notification and evidence action taken to ensure staffing levels are appropriate to meet resident’s needs. Throughout the inspection the deployment of staff within the main lounge area was seen to be inadequate and poor on occasions i.e. lounges left for up to 10-15 minutes without staff presence. The manager’s hours are supernumerary to the above staffing levels and she works Monday to Friday (08.00-16.00). At this time the homes administrator who is contracted for 20 hours per week has had her hours increased to approximately 45 hours per week in order to provide much needed administrative support to the acting manager. Current vacancies include 67x hours for care staff, 14x hours for a care team manager, 50x hours for waking night staff and 36x hours for evening domestic. The records of staff training undertaken by the previous registered provider were muddled and it was very unclear as to what staff training has been received and what remains current and valid. The acting manager confirmed to the inspector that following her own observations of staff care practices, there are many shortfalls pertaining to both mandatory and specialist training for staff. The acting manager was advised to concentrate on providing staff with 6x core training courses relating to dementia awareness, manual handling, protection of vulnerable adults, health and safety, food hygiene and challenging behaviour. The acting manager advised that all care team managers have received appointed first aid training (certificates had not been issued at the time of the site visit), and some staff had received fire awareness training. No clear records were available to indicate as to how many staff had actually attained/undertaken NVQ training. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an acting manager in post who is experienced and qualified to run the home. The registered provider has a quality assurance system in place. The home safeguards individual resident’s monies. Some records as required by regulation were unavailable at the time of the site visit. Formal staff supervision has as yet to be implemented. EVIDENCE: The acting manager has been in post since the 3rd August 2006. The acting manager has previously been a registered manager for Runwood Homes PLC within another establishment and has experience of employment within a dementia unit. The acting manager’s qualifications include the Foundation In Management 325/2, NVQ Level 4 and The Registered Manager’s Award. The Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 22 acting manager is not formally registered with the Commission. Following the site visit an application will be forwarded to the acting manager. Runwood Homes PLC has a quality assurance system in place. It was positive to note that upon purchase of Stafford Hall, an audit was completed on 20th and 21st June 2006, by the quality development manager. Many residents and relatives were spoken with and their comments are highlighted within the report. An annual development plan was readily available highlighting the requirements from the audit report. On inspection of a random sample of individual resident’s monies, records and monetary totals were seen to be satisfactory with systems well organised and audited. A random sample of records as required by regulation were inspected, however some records were not available for inspection. Following the site visit the acting manager was able to forward some documents. The employer’s liability certificate was noted to have expired on the day of the site visit. A copy of the certificate was forwarded to the Commission and this evidences that the insurance is due to expire in August 2007. The homes hoists/slings/assisted baths and passenger lift have all been serviced since Runwood Homes PLC have owned Stafford Hall. The homes gas safety and electrical installation inspection certificates were unavailable on the day of the site visit. Both certificates were forwarded to the Commission however the gas safety certificate was undecipherable and it was unclear as to whether or not the system is deemed satisfactory. Another copy of the certificate must be forwarded to the Commission within 7 days of receiving this report. The electrical installation report deemed the system satisfactory. The registered providers were unable to provide the inspector with evidence depicting fire drill training for staff and there was no fire risk assessment for Stafford Hall. The registered provider must undertake a fire risk assessment of Stafford Hall within the next 21 days and a copy forwarded to the Commission. The assessment must be undertaken by a suitably qualified/competent person. A number of policies and procedures were inspected pertaining to infection control, restraint, challenging behaviour, COSHH (Control of Substances Hazardous to Health) and Health and Safety. None of the policies were read in detail so as to make comment on their content. The acting manager advised the inspector that formal staff supervision is due to be implemented at the beginning of September 2006. The acting manager has set up a cascading supervision schedule and Care Team Manager’s are due to receive supervision training. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 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. 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 3 X 3 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 1 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 2 3 Standard OP7 OP7 OP8 Regulation 15(1) 13(4) 12(1)(a) Requirement Ensure that comprehensive and detailed care plans are devised for all residents. Ensure that risks are identified and as far as possible eliminated. Ensure that proper provision is made for the health and welfare of all residents residing at the care home. Ensure that appropriate arrangements are made for the safe administration of medication in the care home. This refers specifically to medication being given to residents at the correct time as per instructions. Ensure that at all times resident’s privacy and dignity are respected. Ensure that all residents receive an appropriate programme of activities. Ensure that residents are empowered to exercise real choice and control wherever possible about their lives. Ensure that residents are appropriately supervised and DS0000067736.V309995.R01.S.doc Timescale for action 01/12/06 01/12/06 14/10/06 4 OP9 13(2) 14/10/06 5 6 7 OP10 OP12 OP14 12(4)(a) 16(2)(m) and (n) 12(2) 14/10/06 21/10/06 14/10/06 8 OP15 12(1)(a) 14/10/06 Stafford Hall Care Centre Version 5.2 Page 25 9 OP18 13(6) 10 11 12 OP19 OP27 OP27 12(1)(a) 18(1)(a) 18(1)(a) 13 14 15 OP27 OP29 OP30 18(1)(a) 19 18(1)(c)& (i) 16 17 18 19 OP30 OP30 OP36 OP38 13(5) 23(4)(d) 18(2) 23(2)(c) supported at all times. This refers specifically to mealtimes. All staff within the home must receive training relating to dealing with residents inappropriate and aggressive behaviours and protection of vulnerable adults. Ensure that proper provision is made for the health and welfare of residents. Ensure that there are adequate numbers of staff on duty at all times. Ensure that the number of hours provided for activities is reviewed and increased to meet residents needs. Ensure that the deployment of staff within the home is suitable to meet residents needs. Ensure that robust recruitment procedures are adhered to in line with regulatory requirements. Ensure that all staff working at the care home receive appropriate training to the work they perform. This refers to both mandatory and specialist training courses. Ensure that all care staff, receive manual handling training. Ensure that all care staff, receive suitable training in fire prevention. Ensure that all staff are appropriately supervised and records are readily available. Ensure that all equipment provided at the care home is maintained in good working order. This refers specifically to the homes gas safety certificate and the home having a fire risk assessment. 01/01/07 14/10/06 14/10/06 01/11/06 14/10/06 14/10/06 01/02/07 01/11/06 01/11/06 14/10/06 21/10/06 Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 26 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 7 8 Refer to Standard OP5 OP7 OP8 OP9 OP14 OP15 OP18 OP28 Good Practice Recommendations Ensure that there is clear evidence to indicate that prospective residents and/or their representatives are invited to visit the home prior to admission. Residents daily care records should be written after every shift and include an account of the resident’s day, outcomes and staff interventions. Turn charts should be consistently completed in line with individual resident’s requirements and their care plan. The list of staff names, signatures and initials of those able to administer medication should be reviewed and amended. Interaction between staff and residents should be improved. Wherever possible residents should be encouraged to maintain their independence. Ensure that their local policies and guidelines pertaining to protection of vulnerable adults. Ensure that 50 of staff attain and achieve NVQ Level 2 or above. Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Stafford Hall Care Centre DS0000067736.V309995.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!