Inspection on 10/06/05 for Staley House Residential Care Home

This inspection was carried out on 10th June 2005.

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

Staley House Residential Care... 27/02/07

Staley House Residential Care... 22/11/05

Staley House Residential Care... 24/02/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Domain Care Limited Staley House Huddersfield Road Stalybridge SK15 2PT Lead Inspector Janet Ranson Announced 9 & 10 June 2005 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. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Domain Care Limited Address Staley House, Huddersfield Road, Stalybridge, SK15 2PT 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) 0161 304 8939 0161 338 6713 Domain Care Limited CRH - Care Home 27 Category(ies) of DE(E) Dementia - over 65 (27) registration, with number OP Old Age (27) of places PD(E) Physical Disability - over 65 (27) Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 27 service users to include: *up to 27 service users in the category of DE(E) (Dementia over 65 years of age); up to 27 service users in the category of PD(E) (Physical disability over 65 years of age); up to 27 service users in the category of OP (Old Age not falling within any other category). Date of last inspection 24th February 2005 Brief Description of the Service: Staley House is a large detached building converted and extended to provide residential care for up to 27 older people, some of whom may have dementia or a physical disabilty. The property was previously a vicarage. The accommodation is provided on two floors. There are a total of 25 single rooms, 12 of which benefit from en-suite facilities, and one shared room. Located on the ground floor are two lounges and the dining room. In addition to aids and adaptations, there is a full passenger lift. Car parking is provided to the front and side of the building. To the rear is a secure patio area accessed from a lounge that overlooks pleasant lawns and woodland. Garden benches are also provided at the front of the house. The home is located in a conservation area close to the centre of Stalybridge. Domain Care Limited was registered with the Commission for Social Care Inspection as the new providers of care at Staley House on 24th January 2005. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Staley House provides personal care for up to 27 people over 65 years of age. Domain Care Limited owns Staley House in addition to two other homes located in the northwest. The newly appointed manager was on sick leave at the time of the inspection. This was an announced inspection carried out over one and a half days, a total of 11.5 hours. Individual case files and care plans of three residents were examined as part of the inspection process. They concerned people who had lived at the home for a long time, were newly admitted and whose needs were changing. Wherever possible, the residents were invited to talk to the inspector of their experiences and expectations. The inspector also observed staff interaction and practice. A total of six residents’ representatives assisted the inspector with their views of the service. Their comments were positive and they stated they were satisfied with the service. Three staff discussed their roles and responsibilities, they all said they enjoyed working at the home. The new providers continue with the programme of refurbishment and redecoration. What the service does well: What has improved since the last inspection? The care planning format and reviewing process, put in place by the new manager is an improvement on the previous system. The timing of meals has changed with the main meal of the day served at 5:30pm. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 6 The standards of hygiene and cleanliness are very much improved. were no offensive odours apparent. There Laundry equipment has been replaced with commercial washers and dryers installed. The lack of ventilation in this area has also been addressed. Staffing levels have been improved to better meet the assessed needs of the residents. What they could do better: 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. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 7 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 Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 8 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) 3 & 5 Systems are in place to ensure the assessed needs of the residents can be fully met at the home. Prospective residents and their representatives are enabled to visit the home before they consider admission. EVIDENCE: Initial assessments were contained within the four care files examined having been completed by social workers or healthcare professionals. In addition, the home has devised a system of assessment that is also carried out by a senior member of staff. By completing their own assessment the home identifies the individual needs and can reassure the prospective resident that the home would be suitable for them. As part of the home’s assessment process and wherever possible, prospective residents and their representatives are invited to look around the home. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 9 A resident’s representative stated that she had visited Staley House on behalf of her relative and was able to describe the home and the service to her mother. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 10 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, 8, 9 & 10 Residents’ care needs are clearly identified within the care plan and are fully met. All healthcare needs are identified and addressed. Systems are in place to safely handle medication. The resident’s and their families are treated with respect. EVIDENCE: The manager had improved the care planning format. Four care plans were examined; they clearly documented the residents’ assessed needs. The details were well documented and observed. The key workers are responsible for reviewing the plans at regular intervals and for inviting comments and observations from the resident’s family. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 11 Where identified the residents’ healthcare needs are met by the appropriate personnel. The district nurse was in attendance during the inspection. At the time of the inspection arrangements were being made to assist a resident to attend the nearby doctor’s surgery. The home has a medication policy and procedure. The medication administration records for four residents were examined and found to be completed in the approved manner. The manager was in the process of requesting medication reviews from the individual general practitioners. Care plans documented where medication had been reviewed and changed. All carers who are responsible for the administration of medication have received the appropriate training. One resident described how she applied her own ointment but the carers administered her other medications. The interviewed staff demonstrated respect towards the residents and understanding of the need for privacy and dignity. The staff were observed to knock and wait for a response before entering residents’ rooms. The residents’ representatives confirmed that their privacy was respected at all times. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 12 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, 14 & 15 The residents’ individual lifestyles are respected and promoted by the actions of the carers. Visitors are welcomed and encouraged to remain in contact with the residents. Systems are in place to enable residents to exercise control over their financial affairs. Meal times are flexible and relaxed. The menu provides choice and the food is nutritious and well balanced. EVIDENCE: The individual care plan briefly documents the resident’s social history. The carers in discussion were newly in post but understood the implication of this information when caring for the individual. They were able to recount the daily routine that made allowances for those residents who wished to have a lie-in or retire at a later time. It was apparent at the time of the inspection that some residents had chosen to remain in their rooms and this was respected by the carers. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 13 Visitors were to be seen on both days of the inspection. They were greeted at the door in a friendly relaxed manner. A resident’s wife visits every day and always stays for the evening meal. She described to the inspector how much the visits meant to her relationship, and the evening meal was praised for the quality and presentation. Another visitor stated she visited every day and assisted her relative with the evening meal. She said the meals “looked good enough to eat.” The daily choice of menu was displayed on a chalkboard close to the dining room. The main meal of the day had recently been changed to the evening, lunch being a snack type meal. The content of the menu and options were well balanced and nutritious. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 14 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 The residents were confident that their complaints would be addressed. The absence of formal training in the Protection of Vulnerable Adults could result in a resident being put at risk. EVIDENCE: The complaints procedure was available in the service user guide. The residents and their representatives who spoke with the inspector were unable to recall having seen the complaints procedure but were able to tell the inspector how and to whom they would voice their concerns, either to family members or staff. The home has a policy and procedure to respond to allegations of abuse. In discussion, the carers demonstrated their intuitive awareness of abuse and described how they would report concerns to the manager or registered provider. The care staff have not received formal training in the Protection of Vulnerable Adults (POVA) as required. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 15 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, 24, 25 & 26 Staley House provides a warm, clean, safe and well maintained environment with an improved standard of furnishings and fittings. The home is clean with a good standard of hygiene. EVIDENCE: The residents and their representatives who spoke with the inspector voiced their satisfaction with their accommodation. It was noted that some rooms had been redecorated and refurnished to good effect. Many of the bedrooms were nicely personalised and all the doors are lockable. New furniture had been purchased for the lounges and it is understood that a new carpet is to be fitted in the main corridor areas. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 16 A requirement of registration was to address the lack of ventilation in the basement laundry. The registered providers have totally replaced the laundry equipment to commercial standard and have greatly improved the ventilation in this area. The residents and their representatives stated they were satisfied with their washing and ironing. Staley House has had a history of poor hygiene, resulting in areas of the home that were malodorous. This is no longer the case under the new management as physical standards in the home have very much improved. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 17 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, 28, 29 & 30 The home employs staff in sufficient numbers to meet the assessed needs of the residents. The residents receive care from well-trained staff who respond in a respectful manner. The organisation’s recruitment policy and procedure provides protection to the residents from potential abuse. EVIDENCE: The rota provided as part of the pre-inspection questionnaire documented adequate numbers of staff at any one time to meet the assessed needs of the residents. A small group of residents with special needs had been encouraged to use a smaller, quieter lounge located to the rear of the home. A carer is allocated to this area with the result that the residents appeared calmer and were participating in conversation. From observation, the carers were attentive and responded to the residents in a respectful manner. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 18 In addition to care staff, the home also employs catering, domestic and laundry staff. Recruitment is carried out according to the home’s written policies. The staff who spoke with the inspector confirmed they had provided referees and had CRB clearance. The staff files contained the required documentation. The management continues to support carers to complete the National Vocational Qualification at level 2. According to the pre-inspection questionnaire, the number of carers with a level 2 or above currently stands at 50 . Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 19 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, 33, 35, 37 & 38 The newly appointed manager is not registered with the Commission for Social Care Inspection. The residents are involved in the running of the home and can effect change. Systems are in place to protect the residents’ rights, finances and other interests. The residents and staff’s welfare and safety are promoted but the absence of first aid training could affect their health. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 20 EVIDENCE: The newly appointed manager was on sick leave at the time of the inspection. According to the details in the file, she has the appropriate skills and experience to manage the home. She has made several changes to the practices carried out in the home and the residents’ representatives spoke warmly of her. She is now required to make application to CSCI to be registered as a fit person. In discussion with the staff, they were clear that the manager’s communication skills had improved their knowledge of the residents’ needs. The carers said that the manager was approachable and open. All the staff who spoke with the inspector stated they enjoyed working at Staley House and one also stated they felt fulfilled in their role. The registered provider used a system of questionnaires when they became the new owners of the home to elicit the views of the residents and their representatives. The details, including positive and negative comments, are contained within the service user guide. Changes were made to the running of the home as a result of this exercise, which will be repeated every six months. The registered provider is not responsible for the management of residents’ financial affairs. Small amounts of monies are retained for safekeeping and one resident manages their own affairs. The home’s policies and procedures were available for inspection. Record keeping is well organised to a good standard, meeting fully with the requirements. It was noted that access to the residents’ files complies with the Data Protection Act. Risk assessments covering safe working practices, and required at the previous inspection, have been carried out and completed. The new providers have updated the various maintenance contracts concerning gas and electric appliances, and equipment used in the home. The carers who spoke with the inspector stated they had not received training in first aid and one also said she had not been taught to use a hoist. The first aid training was required at the previous inspection. Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 3 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 2 2 x 3 x 3 x 3 2 Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 22 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. 2. Standard 18 31 Regulation 12(1) Requirement Timescale for action 01/10/05 3. 38 The registered person must ensure that all staff are trained in the prevention of abuse. 9(1)(2)(a) The registered person must 01/08/05 (b)(i)(ii) ensure that the newly appointed (c) manager makes an application to be registered by the CSCI. 13(4) The registered person must 01/10/05 ensure that all staff are trained in first aid. (Previous timescale 01/06/05 not met). 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. Refer to Standard Good Practice Recommendations Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton under Lyne OL7 0QD 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 Domain Care Limited F54 F04 s63408 Staley Hse A v223857 090605 Stage 4.doc Version 1.30 Page 24 - 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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