Inspection on 12/10/05 for Stanborough Lodge

This inspection was carried out on 12th October 2005.

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

Stanborough Lodge 21/07/08

Stanborough Lodge 26/06/07

Stanborough Lodge 22/08/06

Stanborough Lodge 13/05/05

Stanborough Lodge 26/08/04

Stanborough Lodge 13/05/04

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 Stanborough Lodge Great North Road Welwyn Garden City Hertfordshire AL8 7TD Lead Inspector Bijayraj Ramkhelawon Unannounced Inspection 12th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stanborough Lodge DS0000019585.V257606.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. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stanborough Lodge Address Great North Road Welwyn Garden City Hertfordshire AL8 7TD 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) 01707 275917 01707 258405 rmd@ukgateway.net RMD Enterprises Limited Ms Sheila Pearce Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th May 2005 Brief Description of the Service: Stanborough Lodge is a detached two storey Georgian-style property that has been converted to its present use. The building comprises of twenty-three bedrooms, each with an en-suite facility. The bedrooms are located on both floors. There are two main lounges one of which is delegated as the smoking lounge, a conservatory and dinning room. There are separate bathrooms and toilets available on each floor. All parts of the building are accessible to persons with restricted mobility. Aids and adaptations include a passenger lift; grab rails and a ramp leading from one door to aid those with restricted mobility access the garden and patio areas. There is a large, well-maintained garden with level pathways. The home is located in a quite cul-de-sac close to the A1M motorway. It is located within short distance from parkland, a local public house, local shops and amenities. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Feedback received from service users, their relatives and visitors was positive. The standard of care and practices observed were high. The majority of time was spent talking to residents, visitors and staff. Some time was spent in the office scrutinising care plans, staff files and other records. There were areas for concerns and these were in relation to Fire Safety practices, Health and Safety issues, and management of medicines and provision of certified training for staff. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must carry out regular audits of Health, Safety and Welfare of service users and staff in ensuring safe working practices including Fire Safety, and compliance with Health and Safety at Work Act 1974. The manager must also devise and implement regular checks and audits in the safe practices and management of medicines. Certified training which meet Skills For Care (previously TOPSS) requirements should be provided for all staff. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 6 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. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 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 the following standard(s): 1-5 Adequate information was available to prospective service users and their relatives to assist them in their decision making process when chosing the home. Each service user has a detailed assessment of needs carried out by the home prior to an offer of placement made. Staff’s approaches and interaction with service users were appropriate to the delivery of care. EVIDENCE: A written ‘Statement of Purpose’ and a ‘Service User Guide’ is in place and both documents were available to prospective and current service users and their relatives. These were also displayed on the general notice board. Service users and relatives spoken to confirmed that they were encouraged to visit the home prior to admission. Care plans scrutinised showed that a senior member of staff had carried out a pre-admission assessment of needs of the service users either in their homes or place of residence prior to admittance. Each service user has received a ‘Terms and Conditions of Residency’ which contained the rights and obligations of the service user and registered provider. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 9 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): 7-11 Care plans were comprehensive and reviewed regularly to reflect the changing health, personal and social care needs of the service users. Service users observed during the course of this inspection appeared to be well cared for, were comfortable and received care and attention in a timely manner. However, particular attention must be paid to the administration and management of medicines. EVIDENCE: Care plans inspected were comprehensive and had all the information required including assessment of needs, risk assessments and how the needs of the service users were being met. These were person-centred, reviewed on a regular basis and signed by the service users/relatives and the progress notes reflected the care plan in practice. Service users who required nursing input were seen by the District Nurse. Each service user has a nutritional assessment on admission but it was noted that individual’s weight was not checked on a regular basis. All service users were registered with a GP, who refers service users to all other health care agencies as and when required. A log of visits from GP, District Nurses and all other health care agents was maintained. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 10 Service users confirmed that GPs and District Nurses visit them as soon as there are any problems and when requested. Service users and their visitors spoken to were very complimentary of the staff and service provision. Records of medicines including the receipt, and storage were kept in good order. However, MAR (Medication Administration Record) sheets did not indicate the correct dosage and frequency but simply stated ‘as directed’. There was hand written instructions made on the MAR sheets, which were not signed by the person making the entries. There were no records of controlled drugs kept in the home. All service users were appropriately dressed and well groomed. The home has a “knock and wait” policy on entering service users’ bedrooms, toilets and bathrooms. Staff members on duty were observed to deliver care and to attend to service users’ needs in a manner that respects their privacy, dignity, choice and wishes whilst actively promoting independence where possible. All personal and intimate care practices were carried out behind closed doors. Doctors and District Nurses also see service users in the privacy of their own rooms. A policy and procedures are in place for care of the dying. It was reported that service users are enabled to stay in the home during their last days. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 11 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): 12-15 Autonomy and choice is promoted. Visitors are welcomed and the home promotes integration with the local community in accordance with service users preferences. EVIDENCE: Each service user has a programme of activities as part of their care plans. The home has employed an activity co-ordinator who organise a variety of activities and entertainment 3 times a week. A number of visitors spoken to were very positive about the home. The home has a selection of large print books and three daily newspapers are also delivered. There is a Church of England service held in the home each month and arrangements could be made to facilitate other religious needs. A hairdresser visits the home twice a week and a mobile library also makes regular visits. The records were quite comprehensive, containing many various activities. Service users manage their own financial affairs with the help of their relatives. Personal belongings were evident in service users bedrooms. Confidential and private information is locked away and care plans are securely stored in an office on each floor. Service users have their relatives or social workers as advocates. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 12 The lunch was unhurried with assistance and encouragement given by staff sitting down next to service users. Tables were laid nicely and a choice of drinks was available and there was individual cutlery. Service users spoken to were complementary of the food provided. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 13 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 A robust complaints procedure is in place of which all service users and visitors spoken to were aware. The manager and the proprietor have a presence within the home thus safeguarding service users. EVIDENCE: A copy of the complaints procedure is available to prospective and current service users. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. There has been no complaints received since the last inspection. Staff spoken to said that they were aware of the ‘Whistle Blowing Policy’. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 14 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): 19-26 The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home was kept clean and generally well maintained and bedrooms were personalised offering a homely, lived in feel. However, training in infection control must be provided for all staff so that service users are protected by good practice. EVIDENCE: The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home was kept clean and generally well maintained. Bedrooms are personalised offering a homely, lived in feel. However, the carpets on the main stairs were worn and torn at the edges and service users stated that their bedroom windows needed to be cleaned. Rooms have locks fitted and service users can be issued with the keys if they wish. The home has adequate number of domestic staff and those spoken to said that they had not had the training in infection control. This may leave service users at risk if good practice in infection control is not observed. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 15 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): 27-30 The skills and experience of staff was varied. There was an enthusiastic, dedicated and caring staff team. However, all training provided for staff should be certified and meet TOPSS now Skills for Care requirements. EVIDENCE: There was adequate numbers of staff rostered on duty per shift during the day and night. There were also adequate number of domestic and catering staff allocated per day and the home has the services of a maintenance person and an activity co-ordinator. Service users spoken to were complimentary about the staff and management of the home. Staff files inspected had all the relevant documents required by this Standard. Some staff spoken to confirmed that they have received appropriate training including NVQ. It was noted that all training provided for staff was not certified. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 16 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): 31-38 The senior staff who have direct involvement, appear to be dedicated to providing a good quality service. However, there were some areas in relation to the environment and practices, which must be addressed to make it safer for both service users and staff. EVIDENCE: The manager and the proprietor communicate a clear sense of leadership within the home and have an open-door policy where staff could see them at any time with any issues or concerns they may have. Service users and their relatives have commented positively on the good practices and quality of service provision. A valid insurance certificate is displayed in the reception area and this offers cover of no less than £5 million. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 17 The organisation’s employment policies and procedures are adopted and facilitates the induction and training programmes for staff. A programme of formal supervision has been developed and implemented. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. Policies and procedures are in place to ensure that the health, safety and welfare of service users and staff are promoted and protected. These records are accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents and admissions to hospital. However, fire doors were again wedged open in the kitchen and service users bedrooms. The bath hot water temperature was 49°C and to reduce the risk of scalding to service users this must be reduced to the safe required level of 43°C. Fire drills were not carried out on a regular basis. The last fire drill recorded was on 12th April 2004. This could leave service users and staff vulnerable if staff are not prepared for an emergency. The Portable Appliance Test was done in June 04. This needs to be completed appropriately to ensure all electrical appliances are safe for use for both service users and staff. The upstairs bathroom was being used for storage. The upstairs corridor carpet and metal strip was loose and elevated which can pose a hazard to service users, staff and visitors. One of the domestic staff said that she was allergic to the gloves provided and she said she had to bring different gloves from her home. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 1 Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 19 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 manager must ensure that MAR sheets must indicate the correct dosage and frequency and not ‘as directed’. Handwritten instructions in the MAR sheets must be signed by the person making the entry. Records of controlled drugs must be kept. Training in infection control must be provided for all staff. Doors must only be held open by means approved by the Fire Safety Officer. (Outstanding from last inspection) Bath hot water temperature was 49°C and must be reduced to the safe required level of 43°C. Fire drills must be carried out on a regular basis. Bathrooms must not be used for storage. Carpet and metal strip loose near upstairs fire door were loose and must be made safe. PAT test must be carried out on yearly basis. Timescale for action 25/11/05 2 3 4 5 OP9 OP9 OP26 OP38 13 (2) 13 (2) 13(3)& 18(1)(c) (i) 23(4)(c) (iii) 13 (4) (c) 23 (4) (e) 23 (2) (l) 23 (2) (b) 13(4)(c)& 23(2)(c) 25/11/05 25/11/05 16/12/05 12/10/05 OP38 6 7 8 9 10 OP38 OP38 OP38 OP38 12/10/05 25/11/05 25/11/05 25/11/05 25/11/05 Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP8 OP38 OP28OP30 Good Practice Recommendations Service user’s weight should be checked on a regular basis. Staff allergic to gloves should be provided with suitable alternatives. All training provided for staff should be certified and meet TOPSS requirements. Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Stanborough Lodge DS0000019585.V257606.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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