Inspection on 03/05/06 for Stambridge Meadows

This inspection was carried out on 3rd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stambridge Meadows 01/04/10

Stambridge Meadows 05/10/09

Stambridge Meadows 16/04/09

Stambridge Meadows 09/10/08

Stambridge Meadows 04/05/08

Stambridge Meadows 09/01/08

Stambridge Meadows 23/08/07

Stambridge Meadows 15/01/07

Stambridge Meadows 31/01/06

Stambridge Meadows 28/09/05

Stambridge Meadows 01/06/04

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 Stambridge Meadows Stambridge Road Great Stambridge Rochford Essex SS4 2AR Lead Inspector Michelle Love Unannounced Inspection 3rd May 2006 08:30 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 Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stambridge Meadows Address Stambridge Road Great Stambridge Rochford Essex SS4 2AR 01702 258525 01702 258229 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) Ashbourne (Eton) Limited Ms Lorraine Louise Reynolds Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49), Terminally ill (2) of places Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Terminal illness to include persons over the age of 55 Date of last inspection 31st January 2006 Brief Description of the Service: Stambridge Meadows is a care home with nursing for up to 49 older people. The home also has a terminal illness category and can care for up to two residents. The home is situated approximately three miles from Rochford Town Centre and is set in pleasant country surroundings. The home has 40 single bedrooms, 33 with en-suite facilities and 5 double bedrooms, 2 of which have en-suite facilities. The home has three lounges, one of which has a designated dining area. The home also benefits from a visitors lounge area on the ground floor. The spacious grounds are well maintained, with several paved areas. The home is in good decorative order with high quality accommodation for residents. Inspection reports are readily available for visitors to the care home and are displayed in the main reception area. Upon request, prospective residents and/or their representatives can have a copy of the last report. The registered provider must ensure that the most recent inspection report is displayed and that individual resident’s Statement of Purpose/Service Users Guide, also have an up to date copy. The range of fees as provided by the homes Operations Manager and Administrator (dated 3.5.2006) are £486.00 for those residents placed in a shared bedroom, £588.50 for those residents receiving residential care in a bedroom without en-suite facilities, £630.00 for those residents receiving residential care in a bedroom with en-suite facilities, £650.00 for those residents receiving nursing care and £750.00 for those residents receiving palliative care. Respite care is charged at £96.50 per day. All other figures are based on the weekly charge for residents. Additional charges to residents include chiropody, hairdressing, newspapers and magazines, personal toiletries and telephone charges. The above information was not detailed within the home’s pre inspection questionnaire as requested. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced `key` site visit whereby all but two key standards were inspected. The visit was carried out by two inspectors, Michelle Love and Carolyn Delaney. The site visit commenced at 07.45 a.m. and finished at approximately 18.15 hours. At this visit a range of records pertaining to individual residents and care staff were examined. In addition several residents and staff were spoken with. Two relatives were spoken with and a number of letters have been sent to residents’ relatives/representatives/professionals following this visit, to seek their views as to the care and support they receive at Stambridge Meadows. These views have not yet been incorporated into this draft report. Once information has been collated, a letter will be forwarded to the registered provider detailing a summary of comments made. Following the site visit to the care home, letters were forwarded to seven resident’s next of kin, requesting comments relating to the quality of care provided at Stambridge Meadows. Relatives stated that for the majority of them they had the opportunity to visit the care home prior to their member of family being admitted. All relatives were provided with literature about the home and had the opportunity to participate within the pre admission assessment process. All but two relatives read a copy of the inspection report displayed in the main reception area. As stated within the main text of the report, this was not a copy of the last inspection report conducted to the home and is seen as misleading. All relatives commented that the care provided at Stambridge Meadows for their member of family was seen to be appropriate and that relatives are/were well cared for. The only criticisms documented relate to there being insufficient stimulation/programme of activities for some individual residents and a number of care practice issues i.e. some care staff slow to respond to nurse call alarms, residents wishes not taken into account pertaining to who provides personal care for them, having a limited number of baths and alcohol hand wash not being readily available. A pre inspection questionnaire was forwarded to the registered manager for completion. It was disappointing to note that this was not received by the due date, some information was recorded inaccurately and other information omitted. The Operations Manager was contacted and information was forwarded to the Commission prior to the site visit. What the service does well: Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 6 Food provided to residents continues to be of a high standard. Residents are offered a varied choice, food is attractively presented and the quantity of food provided is appropriate. Those residents requiring assistance with feeding were supported by care staff with sensitivity and due care. Of those residents and relatives spoken with, all were very complimentary regarding the food provided. Of those residents spoken with, all stated that they liked living at Stambridge Meadows. Relatives spoken with were also very complimentary regarding the care provided, staff working at the care home and the home’s plush environment. What has improved since the last inspection? What they could do better: Improvement is still required in relation to the home’s pre admission assessments/care planning/risk assessments. The Commission recognises that the care manager has a very good understanding of what is required and that this is reflected in documentation completed by her as a random sample of Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 7 records inspected were detailed and comprehensive. Unfortunately documentation completed by others, including the registered manager were not as good and lacked clarity and detail. The registered provider must ensure that information recorded within the pre admission assessment process is also carried forward to the care plan. The healthcare needs of residents must be completed and where food/fluid charts are to be implemented, these must be completed in full. All staff working at the home must receive training pertaining to care planning/risk assessments. Where adaptations and necessary equipment are assessed as being required for individual residents, this must be provided. The Statement of Purpose and Service Users Guide must be reviewed in line with regulatory requirements and contain up to date information. It is unsatisfactory for residents and/or their representatives to be presented with out of date and inaccurate information. The registered provider must look at how the current activity programme is delivered to residents. It is evident that this does not provide for those who have complex needs or who are independent/require mental stimulation. Additionally the registered provider must look at increasing the number of hours available for staff to implement an activity programme. 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. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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 Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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, 4, 5 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service Users Guide is inaccurate and does not provide prospective residents and/or their representatives with correct information so that they can make an informed choice about whether or not Stambridge Meadows is a home they wish to live in. Not all prospective residents had been assessed prior to admission. The registered person was able to demonstrate some improvement in the home’s capacity to meet resident’s needs. EVIDENCE: On inspection of the home’s Statement of Purpose/Service Users Guide, those documents on display i.e. main reception area and within resident’s bedrooms had not been updated and contained inaccurate information relating to the name of the care home, name of the registered provider and the complaints procedure. In addition the Statement of Purpose did not include a copy of the most recent inspection report (31.1.2006). The Statement of Purpose for the newest admission to the care home had a copy of an inspection report dated 1.6.2004. Following the site visit one relative advised the inspector that prior to the inspection and as part of the admission process, the only inspection Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 10 report seen was dated 2005. It is evident that prospective residents and/or their representatives have not been given the most up to date/accurate information so as to make an informed choice as to whether or not Stambridge Meadows is the home they wish to live in. The latter was confirmed by one relative following the site visit to the care home. It remains of concern that the registered manager admitted a resident to the care home, whereby the pre admission assessment was incomplete and there was no evidence to indicate as to how the decision had been made that the home could meet the resident’s needs. No needs were highlighted pertaining to their medication plan, continence assessment, bedroom comfort, eating and drinking assessment, social activities and dementia assessment. Formal assessments relating to dependency and moving and handling were incomplete. Of those other care files inspected for the newest admissions to Stambridge Meadows all had a completed pre admission assessment, which varied in levels of detail and comprehensiveness. In addition to this document, information had been sought from hospitals and/or placing authorities. It was positive to note that information had been recorded as to whether or not prospective residents and/or their representatives had been offered a trial visit to Stambridge Meadows. As a result of shortfalls an `Immediate Requirement` notice was issued. On inspection of a random sample of staff training records and the home’s training matrix, it was evident that mandatory training has been undertaken by care staff since the last inspection, however there was little evidence to indicate that specialist training has been provided. The inspector was advised that the care manager is responsible for co-ordinating training, however she has been unable to undertake this task as the registered manager has been absent from the home and she has had to assume some of the manager’s duties. Despite records being incomplete, following discussions with the care manager and care staff, it was evident that some staff have received specialist training e.g. palliative care and pressure area care. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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, 10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care planning processes within the home have improved since the last visit to the care home, however in some cases information relating to healthcare were inaccurate and of a poor standard. The home’s medication procedures and records were seen to be satisfactory. EVIDENCE: On inspection of eight individual care plans, it was positive to note that documentation was readily available for all. Since the implementation of new care planning formats, formal assessments have been completed pertaining to dependency, pressure sores, falls, manual handling, nutrition and continence. Although some elements of individual’s care plans were observed to be detailed and comprehensive, further work is still required to ensure that care plans and associated documentation detail resident’s health, personal, emotional, physical and social care needs in sufficient respect. Records need to also include staff’s interventions and outcomes. Additionally information recorded within the pre admission assessment, nursing needs assessment and placing authorities must be `cross referenced` to the plan of care. E.g. the pre Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 12 admission for the newest resident admitted to Stambridge Meadows made reference to the individual having a pressure sore on their sacrum and being at high risk of pressure sores, however the care plan recorded that the resident’s skin had no broken areas and that the resident was “not at risk of pressure sores”. Daily care records stated that District Nurse Services were visiting the care home and providing treatment and since the resident’s admission to Stambridge Meadows had conducted two visits on 28.4.06 and 1.5.06. Where some care plans evidenced that food and fluid charts were required to be implemented and maintained not all had been completed in sufficient detail and in some cases no entries were recorded i.e. one resident’s care plan made reference to them requiring assistance with eating and drinking, having a reduced diet, difficulty chewing, weight loss and requiring a soft diet. The care plan did not date as to when food/fluid charts had been implemented/discontinued and there was a distinct lack of charts available (only six records were available for 1.3.06, 3.3.06, 5.3.06, 1.5.06, 2.5.06 and 3.5.06 and these were incomplete). There was clear evidence to indicate that on admission the resident weighed 40KG but on 1.5.06 weighed 34.50KG. Risk assessments were not devised for all areas of assessed risk i.e. one resident’s care plan stated that their care needs related to them being at risk of falls, dehydration, entrapment and asphyxiation by bed rails, choking, constipation, aggressive/inappropriate behaviours, pressure sores and having a poor swallowing reflex. No risk assessments were devised in relation to pressure sores, requiring fluids to be thickened and poor swallowing reflex. The risk assessment pertaining to aggression did not describe the specific nature of inappropriate behaviours possible triggers and how this was to be consistently managed by care staff. Another care plan detailed that the resident’s care needs included weight loss and reduced appetite and that they should be weighed weekly for a short period. Only two entries were recorded depicting the residents weight and no risk assessments were devised relating to weight loss/reduced diet and pressure sores. As a result of the above findings an `Immediate Requirement` notice was issued. The home’s records and safe storage systems for medication were observed to be satisfactory. No omissions of signatures were noted on medication administration records whereby staff had not signed the records to indicate medication had not been administered to and received by residents. Records are kept of all medicines received, disposed of and returned to the pharmacy. Records wherever appropriate also include information relating to details of what actions GP’s have advised i.e. where medication have been discontinued or altered. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. An activity programme is available for residents. The homes arrangements, for resident’s to maintain contact with family and friends remains appropriate. Meals provided to residents are of an excellent quality. EVIDENCE: The home employs three activities co-ordinators for a total of 35 hours per week (Monday to Friday). This continues to be inadequate for the numbers and needs of current residents residing at the care home and must be addressed by the registered provider, as this has been outstanding and highlighted within previous inspection reports. Of those resident’s bedrooms inspected, all were noted to have a copy of the activity programme for May 2006. Activities noted included bingo, scrabble, reminiscence, mobile library, trolley shop, armchair skittles, church fellowship, card games, television/DVD’s and external entertainment. It was observed that the same people appear to participate within the home’s activity programme and that those people who have complex needs/are mentally alert do not receive meaningful activities/stimulation. One resident confirmed that they at times found living within the home boring as a direct result of a lack of activities/stimulation to Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 14 meet their specific needs and that care staff were often too busy to spend quality time with them. The newly appointed project manager advised inspectors that it is Southern Cross Healthcare’s intention for all staff working at the care home to take an active role in the planning and implementation of activities for residents. On the morning of the site visit, three residents were observed to play scrabble, others were chatting and listening to music. Some residents had had the opportunity to sit outside and enjoy the good weather. In the afternoon external entertainment was provided in the main lounge and there was a good attendance from residents. A copy of four weeks rosters were forwarded to the Commission with the homes pre inspection questionnaire. The menus continue to be varied and offer choice to residents at all mealtimes (breakfast, lunch and teatime). In addition to the planned menu’s/choices, residents are able to have alternatives i.e. omelettes, soup, sandwiches etc. The lunchtime meal offered to residents was observed to be appealing and of sufficient quantity. Those residents who require assistance from staff to eat their meals were seen to be supported sensitively and with due care and attention. Resident’s comments relating to food were positive. Residents are able to have their meal either in the lounge/dining areas or in the privacy of their rooms. One relative advised that they were able to have a meal with their member of family when visiting the home. Staff were observed to offer a range of beverages to residents throughout the day. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 a complaints and protection of vulnerable adults policy and procedure. EVIDENCE: The pre inspection questionnaire forwarded to the Commission states that within the last 12 months the home has received 21 complaints and 2 protection of vulnerable adults issues. The log of complaints is inaccurate and 10 complaints have been received in the last 10 months. Since the last inspection the home has received 4 complaints pertaining to fee increases, lack of physiotherapy services, lack of activities, no chef on occasions, care issues for one resident and staff attitudes. Complaints were observed to be well recorded, responded to promptly and in accordance with the registered providers policies and procedures. Outcomes were not recorded, detailing as to whether or not the complaints were upheld or not substantiated. The Commission for Social Care Inspection is still awaiting notification from the registered provider as to the outcome of two protection of vulnerable adults issues. A written response is required within 14 days of receiving this report. The homes training matrix indicated that all but three members of staff have received Resident Welfare training. Records indicate, that no staff working at the care home, have received training relating to Dealing with Challenging Behaviour/Inappropriate Behaviours. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 16 The deployment of staff within the homes main lounge/dining area on the ground floor was appropriate and residents were observed to be supported throughout the site visit. It was positive to note that call alarm facilities for residents were answered promptly by care staff. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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 excellent. This judgement has been made using available evidence including a visit to this service. The home is decorated to a high specification. No health and safety issues were highlighted on the day of the site visit. EVIDENCE: The home is well decorated, all resident’s bedrooms are personalised and individualised and communal areas are homely and comfortable for residents. All areas of the home were observed to be clean, tidy, well maintained and odour free. New carpets, were observed to be laid within the main reception area and all communal corridors on the ground floor. It was positive to note that the company responsible for laying the carpets had displayed risk assessments and notices in all affected areas. Some impact was noted pertaining to resident’s normal activities i.e. restricted access to some areas. Work was observed to be carried out promptly so as to minimise any significant impact. Of those rooms inspected all were noted to have hand towels/flannels readily available. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 18 No health and safety issues were highlighted at this site visit. Following the site visit, one relative advised the inspector of their disappointment that a specialist hospital bed had not been provided for their relative receiving palliative care, despite assurances from the registered manager that one would be available upon admission. The registered provider must ensure that as part of the pre admission/assessment process any equipment/adaptations required are sought and in place prior to the person’s admission to the home. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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 good. This judgement has been made using available evidence including a visit to this service. In general staffing levels are being maintained at Stambridge Meadows. Recruitment procedures within the home were not formally assessed as no new staff, have been recruited. Training is provided for staff however recording is inconsistent in some areas. EVIDENCE: Since 25.3.2006 the Commission for Social Care Inspection has received four Regulation 37 Notifications advising that staffing levels have not been maintained in accordance with the minimum staffing levels as set by the previous registration authority. No information was available to evidence what steps had been undertaken by the registered manger/provider to get additional staff/ensure staffing levels were compliant. Staff rosters indicated at all other times that staffing levels were appropriate. No staff were rostered to work over 48 hours and all staff were observed to have a minimum of two off duty days per week. The staff rosters detailed start and finish times of duties and allocations of staff covering nursing and residential areas. No new staff, had been recruited since the last inspection. Both the training matrix and individual staff training files do not evidence specialist training undertaken by staff. As stated previously it is the care manager who is responsible for co-ordinating training, however she has not been able to do this in the absence of the registered manager and has been Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 20 required to undertake managerial duties. The training matrix details that all staff have attained Manual Handling, all but six staff have Health and Safety, all but two staff have Basic Food and Hygiene, all but three have Resident Welfare and all but five members of care staff have attained Fire Awareness. On inspection of one staff file (domestic), there was no evidence of training. Despite a lack of up to date records pertaining to specialist training, staff advised the inspector that some training has been attained relating to pressure area care and palliative care. The registered person must ensure that specialist training is provided which meets the needs of residents and those conditions associated with older people. NVQ records need to be reviewed as it is not clear who is actually undertaking NVQ training and some staff who had achieved this qualification have since left the home. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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, 32, 33 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Currently the home is being overseen by a project manager. Staff within the home receive formal supervision on a regular basis. EVIDENCE: The Commission recognises that the registered manager has tried to address some of the shortfalls as identified at the last inspection to Stambridge Meadows. Unfortunately some of the evidence accumulated is inaccurate and has not been completed in line with regulatory requirements. The Commission is aware that following the last inspection additional support was given to assist the registered manager in meeting the registered providers targets and ensuring that care practices and recording improved to a suitable level and in line with National Minimum Standards/Care Homes Regulations for Older Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 22 People. Where gaps still exist it is surprising that these were not picked up by the home’s Operations Manager. As a result of the registered manager’s absence the registered provider has employed a Project Manager to oversee the running of the home on a day-today basis. It was positive to note that the Project Manager has a very good understanding of National Minimum Standards/Care Homes Regulations for Older People and what constitutes good professional practice. The Project Manager appeared very committed and focussed and both inspectors felt assured that identified shortfalls would be addressed within a reasonable time frame. At this site visit there was clear evidence to indicate that the care manager was playing a more active role, was coping well with her new responsibilities and liasing positively with the newly appointed Project Manager. Records indicated that formal staff supervision have been undertaken at the home since the last inspection. Records for individual staff were observed to be sealed and therefore were not inspected fully. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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 2 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X X Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 4 and 5(d)(e) Requirement The registered person must ensure that the Statement of Purpose and Service Users Guide is reviewed in line with regulatory requirements and contains the most recent inspection report. (Previous timescale not met) The registered person must ensure that all residents are assessed prior to admission and these are detailed and comprehensive. (Previous timescale of 14.2.06 not met) The registered person must ensure that care plans are detailed and comprehensive. (Previous timescale not met) The registered person must ensure that healthcare records are detailed and comprehensive and these detail staff’s interventions and outcomes. The registered person must ensure that risks to residents are DS0000015554.V292330.R01.S.doc Timescale for action 01/07/06 2. OP3 14 01/06/06 3. OP7 15(1) 01/07/06 4. OP8 12(1)(a) 01/06/06 5. OP7 13(4)(c) 01/06/06 Stambridge Meadows Version 5.1 Page 25 identified. 6. OP8 17(1)(a), Sch 3 (Previous timescale not met) The registered person must document information relating to pressure sores and ensure these are recorded within individual care plans. (Previous timescale of 1.1.06 not met) The registered person must ensure that complaints detail outcomes. (Previous timescale of 1.3.06 not met) The registered person must ensure that the number of hours provided for activities for residents is increased to meet demand and need. The registered person must ensure that activities are provided for those residents who have complex/independent needs. The registered person must ensure that staff working within the care home, receive training to deal with residents aggression and inappropriate behaviours. The registered person must ensure that appropriate equipment and adaptations are provided for residents. The registered person must ensure that sufficient numbers of staff are on duty at all times. The registered person must ensure that all staff receive appropriate training to the work they perform. Ensure that all staff at the care home undertake appropriate training to the work they perform and have the necessary skills and expertise to meet the DS0000015554.V292330.R01.S.doc 01/06/06 7. OP16 22(3)(4) 01/06/06 8. OP12 18(1)(a) 01/08/06 9. OP12 16(2)(m) and (n) 01/06/06 10. OP18 13(6) 01/09/06 11. OP19 23(2)(n) 01/06/06 12. 13. OP27 OP30 18(1)(a) 18(1)(c) 01/06/06 01/10/06 14. OP30 18 (1)a & 18 (1)c 01/07/06 Stambridge Meadows Version 5.1 Page 26 specialist needs of residents. , 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. Refer to Standard OP15 OP28 Good Practice Recommendations Nutritional, fluid and food charts should not be muddled and they should be completed wherever necessary. 50 of care staff achieve NVQ Level 2 or equivalent. Stambridge Meadows DS0000015554.V292330.R01.S.doc Version 5.1 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. 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