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Inspection on 13/02/06 for Stamford Nursing Centre

Also see our care home review for Stamford Nursing Centre for more information

This inspection was carried out on 13th February 2006.

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.

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

What the care home does well

Service users benefit from good detailed assessments that are reflected in their individual plans to ensure continuity of care by staff. Service users benefit from knowing that appropriate risk assessments are in place and that any falls are monitored closely, action is taken to ensure the safety of service users including additional staff support. Service users benefit from good health care input including the close management, monitoring and prevention of falls. Service users feel that they are treated with respect and that they are listened to. Service users benefit from regular contact with family and friends and a good variety of activities are offered within the home to meet the service users social and cultural expectations. Service users benefit from good quality food that they enjoy. Service users benefit from having specific dedicated staff teams on each floor to support them. Service users benefit form living in a very comfortable, safe homely environment with ample communal and private space.

What has improved since the last inspection?

Seven requirements were made at the last inspection. Five had been achieved at this inspection. Requirements concerning medication had mostly been met to safeguard service users however two requirements had not been met these have been restated in the relevant section of the report. Other requirements that had been met concerned the appropriate storage of the dustpan and brush away from the food preparation area. Staff have now received refresher training in the care of diabetic service users and the call bell cords are now in most cases long enough to reach the floor although an audit of all the rooms would be useful.

What the care home could do better:

Two of the requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. In the `timescale for action` column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about the unmet requirements can be found in the relevant standard. Further requirements made concerned the Statement of purpose and service users guide to be amended and for a copy to be sent to the Commission and for annual placement reviews to be carried out by the placing authorities to confirm the suitability of the home for the individual. Requirements concerning the staff included the need for refresher training in adult protection reporting procedures, training in the management of challenging behaviour and sexualised behaviour and for two company stamped references to always be obtained prior to employment to safeguard service users. Requirements made concerning the management of the home focused on the need to recruit a manager and for them to apply to the commission to become registered. A requirement was also made for fire drills to take place on a three monthly basis. Two recommendations were made; one concerned seeking advice from the fire authority with regard to practical evacuations and for the pooled bank account to be on the agenda for change to individual bank accounts for service users.

CARE HOMES FOR OLDER PEOPLE Stamford Nursing Centre 21 Watermill Lane Edmonton London N18 1SU Lead Inspector Rebecca Bauers Unannounced Inspection 10:30 13 February 2006 th 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 Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stamford Nursing Centre Address 21 Watermill Lane Edmonton London N18 1SU 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) 020 8807 4111 020 8807 9479 ANS Homes Limited Care Home 90 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (43), Physical disability (14) of places Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home will provide accommodation for up to 90 service users of either gender. 43 of the 90 service users will be over 65 years of age and require nursing care. To provide nursing care to 14 service users aged between 21 and 65 years of either gender. Care for these service users is to be provided in a `Young Adult Physically Disabled Unit` situated on the first floor of the home. The unit must have a team of staff specifically dedicated to it and this must be indicated on staff files and duty rosters. To provide a dedicated unit for people over the age of 50 years with a diagnosed dementia who also require nursing. Specifically to provide for 33 service users of either gender aged over 50 years of age. The unit being sited on the second floor of the existing building. The unit must have a team of staff specifically dedicated to it and this must be indicated on staff files and duty rostas. 4th July 2005 4. Date of last inspection Brief Description of the Service: Stamford Nursing Centre is a care home registered to provide nursing care for older adults and a specified number of younger adults with physical disabilities. The home was previously owned by ANS Homes Limited, however BUPA purchased the home in October 2005 and so the home is currently going through some transitions. All the existing staff team were transferred under TUPE and so continue to work in the home. BUPA is a national organisation and provides services across the UK. The home continues to aim to provide a high quality of nursing care to adults convalescing after surgery or illness, older people who require nursing care, adults aged over fifty with physical disabilities and those requiring palliative care. The home is a large modern purpose built three storey building. The kitchen, laundry, reception and administrative offices are all located on the ground floor. The bedrooms are located on all three floors and all of them have ensuite facilities. Floors are connected by stairways and a passenger lift. Each floor has a lounge and separate dining room. There are two additional smaller lounges. Smokers use one of these lounges. Fourteen younger adults are accommodated in a separate wing on the first Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 5 floor. The home is located close to the North Middlesex Hospital and along the North Circular Road. It is within walking distance of shops; restaurants and transport facilities located the High Street in Edmonton. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 13th February 2006 and took approximately seven hours to complete. The pharmacist inspector visited the home for two and a half hours on the 16th of January. Progress was checked with requirements made at the last inspection. Since the last inspection the registered manager has left her post and the deputy manager is the acting manager. BUPA purchased the home in October 2005. As a result of this the home is going through a transition period. The acting manager and operations manager were present during the inspection. Both were very helpful and present for the feedback following the inspection. Eight service users were spoken to either individually or as a small group. Service users were positive with regard to the care they receive. Four staff and two relatives were spoken to individually or in pairs. Positive comments were made by both groups and staff morale is high. A full tour of the building took place, which included looking at some of the service users bedrooms with their consent. Care, finance records, staff records and health and safety records were all examined. Further information was obtained through observation of staff and service user interactions. What the service does well: Service users benefit from good detailed assessments that are reflected in their individual plans to ensure continuity of care by staff. Service users benefit from knowing that appropriate risk assessments are in place and that any falls are monitored closely, action is taken to ensure the safety of service users including additional staff support. Service users benefit from good health care input including the close management, monitoring and prevention of falls. Service users feel that they are treated with respect and that they are listened to. Service users benefit from regular contact with family and friends and a good variety of activities are offered within the home to meet the service users social and cultural expectations. Service users benefit from good quality food that they enjoy. Service users benefit from having specific dedicated staff teams on each floor to support them. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 7 Service users benefit form living in a very comfortable, safe homely environment with ample communal and private space. What has improved since the last inspection? What they could do better: Two of the requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. In the ‘timescale for action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about the unmet requirements can be found in the relevant standard. Further requirements made concerned the Statement of purpose and service users guide to be amended and for a copy to be sent to the Commission and for annual placement reviews to be carried out by the placing authorities to confirm the suitability of the home for the individual. Requirements concerning the staff included the need for refresher training in adult protection reporting procedures, training in the management of challenging behaviour and sexualised behaviour and for two company stamped references to always be obtained prior to employment to safeguard service users. Requirements made concerning the management of the home focused on the need to recruit a manager and for them to apply to the commission to become registered. A requirement was also made for fire drills to take place on a three monthly basis. Two recommendations were made; one concerned seeking advice from the fire authority with regard to practical evacuations and for the pooled bank account to be on the agenda for change to individual bank accounts for service users. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 8 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. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 9 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 Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 10 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 The home conduct detailed assessments of need prior to admission to the home. Service users feel that their needs are understood by staff although the placing authorities are not reviewing the placements to ensure that they remain appropriate for the service user. The homes statement of purpose and service users guide is not yet available and is under review to ensure that all prospective service users will receive the information they need to make an informed choice about where to live. EVIDENCE: Ten service user files were examined and were found to contain comprehensive assessments of need. Service users spoken to felt that their needs were understood and met by the staff. Service users spoke highly of the staff, stating that I cant fault them, they are very caring and sociable’ In house reviews had taken place and were held on file, however, placement reviews were sporadic in fact only one of the ten files seen contained a placement review, which was carried out in 2004. It is essential that the Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 11 placing authorities conduct annual reviews to ensure that the placement is still appropriate for the individual. The homes statement of purpose and service users guide is currently under review in the light of the recent purchase of the home by BUPA. An amended copy must be sent to the Commission. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 12 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 Good individual plans of care are in place, which set out detailed consistent support needed to meet the individual health, personal and social care needs of service users. Service users health care needs are fully met to promote good wellbeing. Service users are protected by the homes medication policy and procedures. EVIDENCE: Each service user has a comprehensive plan of care, which includes all health, personal, and social care needs. This plan of care also includes clear, consistent support needs to ensure the continuity in the provision of care by staff. There was evidence that they are reviewed monthly and any changes in need noted. Appropriate risk assessments are in place to safeguard service users. Health records were detailed and identified all health needs and intervention by the home and health care professionals. This included the management of pressure sores, nutritional assessments, management of MRSA, physiotherapy, chiropody occupational therapy, dietician and speech and language input. The Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 13 GP visits the home every week and all service users have a medication review at least every six months. There was evidence of good management of accidents and incidents to safeguard service users. There had been a marked decrease in the number of accidents last twelve months. Each accident/incident had been reviewed and alternative precautions to safeguard service users had been put in place. For example additional supervision or hip protectors had been purchased for the individual. The pharmacist inspector visited the home on the 16th of January to check progress with the four requirements made at the last inspection. The findings were as follows: The medication policy is satisfactory. According to the staff no medication is being disguised. The records for the receipt, administration and disposal of medication were found to be satisfactory. The medication profiles are generally up to date, except on the top floor the ordering for December had not been put onto the standard form. There was, however, a copy of the service users’ prescriptions for December/ January. The new cycle of medication had started on the ground floor the morning of the inspection. Two items still owed but the company had promised to deliver them that day. One item was not required until the evening. There was no evidence at the time of the inspection that items such as lactulose were being given to a service user from another service user’s labelled bottle. Some medication has been deleted which was prescribed ‘to be given when required’. A few items remain where more explicit written instructions are required as to the circumstances when the staff should administer the medication. The temperatures of the clinical rooms are monitored and remain below 25oC. The temperatures of the fridges remain between 2-8oC. PEG feeds are now stored in the clinic rooms or service users’ rooms where the temperature can be maintained at 25oC or below. The storage and control of Controlled Drugs was found to be satisfactory and the stock of liquid preparations can now be checked using a measuring cylinder. The records in the Controlled Drug Register were found to be satisfactory. Medication training is being organised by the company, as some staff have not recently attended courses involving new medication and legislation. Two requirements were restated and can been found in the relevant section of the report. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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): 12,13,14,15 Service users express positive experiences of living in the home and feel that their social, cultural needs and general interests are adequately provided for. Family and friend contact is promoted and service users feel that they are able to exercise a level of control over their lives. The food provided in the home is balanced, well presented and very popular with the service users. EVIDENCE: Service users commented ‘ its like heaven on earth here’ can I say that? The staff are lovely’’ I cant fault them, they take there time when they help us theirs no rushing about.’ Other service users spoken to stated that they are able to do what they like, so if they want to join in with planned activities arranged by one of the three activities co-ordinators they can or if not they can watch TV, listen to music, chat with staff. Some have a daily paper delivered. An entertainer is booked every fortnight and church services are also held every two weeks. All activities are clearly advertised on the notice boards on each floor. Service users spoken to felt that their views are listened to and that they are able to exercise some choice and control, over their lives through the service user meetings that are held every three months. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 15 Service users spoken to were particularly positive with regard to the food provided. Observations of staff interaction with service users during meal times were seen to be calm, respectful, engaging and enjoyable. Service users were able to read the menus on their individual tables, which included an alternative. The dinning rooms were very pleasant and all the tables had been laid with fresh flowers and fabric serviettes. All dietary needs had been noted in the individual plans and in the kitchen. Relatives were positive with regard to the care and the food provided in the home. Service users spoken to again confirmed that their relatives and friends are able to visit them when they wish. All service users have access to a phone to make private calls; some service users have their own telephone lines in their bedroom. A requirement made for the dustpan and brush to be stored away from the food preparation area or in a locked cupboard had been fully complied with. They are now housed in a cupboard. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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): 16,18 Service users and relatives feel that their views are listened to and acted upon. Service users are protected by the homes adult protection procedures although staff are not fully aware of the outside agencies that they need to report to in the event of and allegation being made to protect service users. EVIDENCE: Service users and relatives alike were knowledgeable with regard to the complaints procedure and knew who they could talk to in the event that they were unhappy about the service they were receiving. No complaints were made during the inspection. The complaints record indicated that no complaints had been made since the last inspection. Staff spoken to had received training in ‘elders abuse’ and knew that in the event of an allegation being made they would record and report to their line manager. However when asked what other agencies needed to be informed the staff were not so clear. It is essential that staff feel confident and know who to report allegations of abuse to in line with the homes and local authorities adult protection procedures to safeguard service users. There have been no adult protection issues. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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): 19,20,21,22,23,25,26 The home is very comfortable, safe and homely. Good facilities and specialist equipment is available to service users to promote independence. Al rooms had been personalised, clean and hygienic. EVIDENCE: During a tour of the home it was evident that service users are benefiting from living in a well maintained, homely comfortable environment. All the bedrooms visited were clean, hygienic and had been personalised by the individual living in the particular bedroom. Communal areas were spacious and well decorated, service users were observed spending time in different areas of the home and those who were able to mobilise independently often spent time on different floors. Some service users spent time with each other in their rooms chatting or watching TV. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 18 The home is well equipped with specialist equipment to maximise service users independence. There are ample bathrooms and en-suite facilities for all service users. Communal hallways had recently been re-carpeted and all rooms are decorated prior to an individual moving into the room. All bedroom doors have now been fitted with self-closing devices, which when the fire alarm sounds the doors automatically close. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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): 27,29,30 Service users needs are met by the number and skill mix of staff. Service users are generally well protected by the homes recruitment practices. Staff are generally well trained to meet the needs of the service users. EVIDENCE: A requirement made at the last inspection for all staff to update their training in the care of service users with diabetes had been fully complied with. Training took place on the 12/8/05 by a clinical nurse specialist. Training records demonstrated that all staff attended this. The rota was seen and demonstrated that there are sufficient staff on duty to meet the needs of the service users. Staff and relatives felt that the staffing levels were adequate. The home does not use agency staff and has its own ‘bank’ staff to facilitate continuity in care for service users. Staff records demonstrated that service users are generally protected by the homes recruitment policies and procedures. One of the five staff files looked at only had one reference on file. This is not acceptable there must always be two. All other documentation was available. For example CRB certificates. It was evident from the individual plans that many of the service users who suffer from dementia also exhibit challenging behaviour and in some cases present sexualised behaviour toward the care staff. There was no indication that staff had received training in this area, although some staff spoken to were able to demonstrate some knowledge of how to deal with these Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 20 situations. All staff must receive this training to ensure confidence and continuity in the management of these issues. Staff spoke very positively about working in the home and felt that staff morale was good. Service users spoke highly of the staff stating that they were ‘caring and kind’ Staff were positive with regard to the recent take over by BUPA and felt that the process had not been disruptive in anyway. They felt that they were able to continue to practice as before. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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): 31,32,35,37,38 The acting manager is running the home well in the absence of the registered manager; the vacant post is being recruited. Staff are supervised and feel well supported. Service users financial interests are safeguarded by the home. The health, welfare and safety of service users are protected. EVIDENCE: The home does not have a registered manager. The deputy manager has been acting manager since December 2005. The acting manager has over twenty years experience of working as a nurse and as a manager in other residential services. The inspector was informed that the first round of interviews to recruit a new manager had been unsuccessful, however another recruitment drive has taken place, interviews are planned for the next few weeks. It is essential that a manger is recruited and that they apply to the Commission to become registered. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 22 There was evidence that staff receive regular supervision, as there were records of these on file. The acting manager confirmed that since the registered manager left in December her workload has doubled, as she is now responsible for all staff supervisions. Staff spoke highly of the acting manager and felt that the home was well organised and that they felt well supported. The home is currently going through a transitional stage in respect of policies and procedures; this has been ongoing since October 2005 since BUPA took over the home from ANS. The operations manager and the acting manager are liaising regularly to ensure that all polices and procedures are implemented efficiently and with minimal disruption to both service users and staff. The inspector checked the finances of service users and found that accurate records of monies incoming and outgoing were up to date and there was a clear audit of receipts. However the inspector was informed that service users pensions and/or benefits are paid into a non-interest pooled bank account. It is recommended that the registered person seek advice with regard to each service users having an individual account. Relatives are in most cases appointees. Fire records were checked and found to be up to date. However the last fire drill was carried out in June 2005. The fire authority recommends three monthly fire drills. In addition, it would be advisable to check with the fire authority the frequency of practical evacuations given the size of the home and needs of the service users. This advice should be sought to safeguard service users in a fire to ensure that all staff are clear with regard to evacuation points and how to evacuate quickly and safely. Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 X 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 X 3 2 Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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 OP9 Regulation 13(2) Requirement The registered person must ensure that there are clear, signed instructions by the GP for any medication that is labelled to be administered as directed by the GP. This requirement is restated. Timescale for action was 13/8/05. Timescale for action 13/04/06 2. OP9 13(2) 3 OP1 6(a)(b) 4 OP4 14(2)(a) 13/04/06 The registered person must continue to work with the supplying pharmacist to ensure that medication is received into the home, with time for it to be checked in and omissions corrected prior to the medication being required by service users. This requirement is restated. Timescale for action was 13/8/05. The registered person must 13/04/06 ensure that a copy of the revised ‘BUPA’ statement of purpose and service users guide is sent to the Commission. The registered person must 01/07/06 ensure that the placing authorities conduct annual multidisciplinary review meetings DS0000027823.V271200.R01.S.doc Version 5.0 Page 25 Stamford Nursing Centre 5 OP18 6 OP29 7 OP30 8 OP31 9 OP38 for each service user to ensure that the placement in still appropriate and that the home is able to meet the individuals assessed needs. 13(6) The registered person must ensure that all staff are confident and are familiar with the reporting procedures in the event of an allegation of abuse being made. This must include knowledge of the outside agencies that needs to be contacted. For example the ‘host authority’ and the Commission. 17(2) Sch The registered person must 4 (6) ensure that prior to employment two references are obtained that include the company stamp or a compliments slip and that these are held on the staff members file. 18(1)(c)(i The registered person must ) ensure that all staff undertake training in the management of challenging behaviour and sexualised behaviour that can be as a result of dementia care needs. 8(1)(a)(2) The registered person must ensure that a manager is appointed to manage the home and that they apply to the Commission to become registered. 23(4)(e) The registered person must ensure that fire drills are carried out every three months. 01/04/06 13/03/06 01/05/06 01/04/06 01/03/06 Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 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 Refer to Standard OP35 Good Practice Recommendations It is recommended that the registered provider look at the possibilities of providing service users with their own bank accounts for pensions to be paid into instead of one pooled bank account. It is recommended that the registered person seek advice from the fire authority with regard to the frequency in which practical evacuations should occur. 2 OP38 Stamford Nursing Centre DS0000027823.V271200.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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