Inspection on 21/07/08 for Stanborough Lodge

This inspection was carried out on 21st July 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Stanborough Lodge 26/06/07

Stanborough Lodge 22/08/06

Stanborough Lodge 12/10/05

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 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Stanborough Lodge Great North Road Welwyn Garden City Hertfordshire AL8 7TD Lead Inspector Marian Byrne Unannounced Inspection 21st July 2008 10:30 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 Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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.V369074.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2007 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. Information regarding the service is available in the Statement of Purpose and Service User Guides. These documents and a copy of the most recent inspection report should be available on request from the manager. The fees range from £385 - £496 per week. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. One inspector carried out this inspection over a period that covered late morning and the afternoon. We looked at relevant documentation including service user and staff files. We spoke to people living and working in the home to gain their views of life in Stanborough Lodge. We spent some time with the manager and one of the owners of the home. Surveys were sent out to the residents and their families. We had a high number returned. What the service does well: The Manager and staff of the home are dedicated to meeting the needs of the residents. They know the resident’s needs and are proactive in meeting them. The day of the inspection was a lovely sunny day and the doors were open to the garden many of the residents were enjoying a stroll around the garden paths. These paths offer the residents a safe walkway. The dining room was beautifully prepared for lunch and residents were observed to be enjoying lunch while chatting to each other and the staff. Residents spoken with stated that they were very happy with the care offered and delivered to them. We sent out surveys to the people who live in the home and we had a very good response from them. Here are some of the things the residents said about the home: ‘I enjoyed the musical quizzes, sing-a-longs and armchair exercises’. ‘That the home was nice and clean’. ‘I am asked in the morning what I would like for lunch, there is usually a choice’. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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.V369074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that their needs will be identified prior to admission and that the home will not offer them a place unless they can meet their needs. EVIDENCE: We looked at three admission assessments and there was evidence that a thorough assessment has taken place. The Registered Manager or a senior care worker carries out a full assessment of need before an admission takes place if the home cannot meet the needs of the prospective resident they will not offer a place to that person. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that their care needs will be met in a manner that upholds their dignity. Medication was not always administered from its original container this means that a mistake could be made and could have an adverse effect on the health of the resident. EVIDENCE: We looked at three care plans and found them to contain very good information on the residents. Where needs were recognised there were good directions to staff on now to meet that need. Health Professionals who responded to our survey indicated that they were happy with the health care of the residents. They also stated that the home recognises the limits of care and when they are no longer able to meet the health care needs the resident is referred to a nursing home that will be better able to meet their needs. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 10 All our observations and responses to our surveys and speaking to residents assured us that all residents were treated with respect and dignity and their rights to privacy was respected. The administration of medication and recording of medication was not carried out in accordance with the guidelines from the Royal Pharmaceutical Society. The home was not administering medication directly from the original container. Rather they were decanting to a small personal contained to take upstairs. This could contribute to mistakes being made and people being put at risk. This was discussed with the manager at the time of the inspection. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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. 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. People who use this service can be sure that visitors are welcomed at all reasonable times. However, not all residents’ experiences in the home match their preferred lifestyle. The food is served in a pleasing manner, which meets people’s needs and expectations. EVIDENCE: There are regular organised activities in the home, however the Registered Manager and staff need to give consideration to the day-to-day life in the home and provide on going stimulation for the residents. On the day of the inspection we did not observed any organised activities. We noted that the television was on but the sound was down therefore it impossible to anybody to follow the programme if they wished to. Staff did not appear to be aware of this as they carried on with their tasks. We saw that some of the people who were in the sitting room were chatting to each other. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 12 However, we noted that others were withdrawn. The withdrawn state we observed could be due to a lack of stimulation. There was no reading material or craft items (or similar) available at hand for residents so to offer occupation or stimulation. However there is an area of the sitting room that is designed for reading but this was not in use on the day of the inspection. The Registered Manager told us she would have a re-think of the lay out of the room. We were told that visitors are welcomed to the home at all reasonable times. Mealtime was conducted at a leisurely pace in the dining room. We saw that the tables were set very nicely and the food was served in an orderly manner and the residents did not have to wait too long to be served. The food was of good appearance. The residents appeared to enjoy it. Some of the comments we received were that the resident ‘enjoyed the musical quizzes, sing-a-longs and armchair exercises’ and ‘I am asked in the morning what I would like for lunch, there is usually a choice’. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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. 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. People who live in this home can be assured that their complaints will be listened to and investigated and that they will be protected from abuse. EVIDENCE: Complaints are investigated. However, care needs to be taken to include the resolution of a complaint in writing to the people involved so that they will have a full understanding of the investigation. The residents spoken with assured us that there if they had a problem they would talk to staff or the Registered Manager. It must be noted that the recruitment of staff could have potentially put residents at risk of abuse as a Criminal Records Bureau clearance had not been received prior to that member of staff starting to work alone in the home. A check had been made to ensure that the member of staff had not been on the Protection of Vulnerable Adults list prior to that member of staff starting work. Two further staff members from outside the United Kingdom had started work without the required references. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that they will live in a clean, fresh environment that is safe and well maintained and meets their needs. EVIDENCE: On the day of the inspection the home was clean and fresh and well maintained. People’s rooms were personalised and reflected their individuality. The doors were open to the grounds and residents were walking in the garden. The garden provides safe pathways to ensure the safety of the residents. However, there is nothing in place to stop vulnerable people leaving the grounds of the home and wandering into the road. To date this hasn’t been a problem but as the people who are admitted and some of the people who live there have short-term memory loss it is an area that needs consideration and Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 15 appropriate risk assessments. The Registered Manager assured us that she would investigate all the issues relating to this. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service can not be assured that the recruitment process is robust so to ensure that unsuitable people are not employed to work with vulnerable people. Residents can be sure that the training given to staff ensures they are competent care for them. EVIDENCE: There were sufficient staff on duty to meet the needs of the residents. Training is carried out to ensure all the needs wants and wishes where possible are met in a manner that promotes the dignity of the residents. One member of staff recently recruited did not have Criminal Records Bureau clearance. She was working unsupervised with residents at night. We left an immediate requirement for this to cease until her clearance had been received by the home. Two further members of staff had been recruited without two recent references being authenticated by the manager. The references on file were photocopied ‘to whom it may concern’ open references. An immediate requirement was also left on this. The home responded quickly and both of these requirements have now been confirmed by the home as met. The Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 17 judgement for this outcome would have been poor had the home not reacted to promptly to our immediate requirement and given us an assurance that their recruitment mistake would never happen again. The provider and the Registered Manager must review their recruitment practices and the paperwork used. A full employment history on the application form will assist the Registered Manager in knowing if the applicant is suited to working with very frail elderly people. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be assured with some exceptions that the home makes every effort to ensure that the home is well run in the best interests of the people who live there and that their health and welfare is promoted. EVIDENCE: Surveys received indicate that the residents of Stanborough Lodge are happy with the care they are given and the manner in which it is delivered. The Registered Manager and the responsible individual must be aware of their legal obligations when they are employing staff. Failure to comply with regulations could put the residents at risk. When employing staff the Registered Manager must be able to evidence that the home has a robust Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 19 recruitment policy that meets the requirements of Employment Law. The judgement for this outcome group would have been poor had the home not reacted to promptly to our immediate requirements and given us an assurance that their recruitment mistake would never happen again. The home has a plan in place should there be a fire in the home. All equipment was maintained. The home does not manage any of the residents money. Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 20 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 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X x Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 the administration of medicines is appropriately recorded. Medication must always be administered from its original container. The Registered Person must ensure that all staff have a Criminal Records Bureau clearance before they work unsupervised with residents. He/she must also ensure that each member of staff has two references that can be authenticated prior to starting work. An immediate requirement was left on this. The service has confirmed that the requirement has now been met. Timescale for action 21/07/08 2 OP29 19 21/07/08 Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stanborough Lodge DS0000019585.V369074.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V369074.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!