CARE HOMES FOR OLDER PEOPLE
Standon Hall Care Home Standon Nr Eccleshall Stafford Staffordshire ST21 6RA Lead Inspector
Mrs Yvonne Allen Key Unannounced Inspection 24 May 2006 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 Standon Hall Care Home DS0000022376.V296589.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. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Standon Hall Care Home Address Standon Nr Eccleshall Stafford Staffordshire ST21 6RA 01782 791555 01782 791396 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) Standon Hall Home Limited Mrs Beverley Davies Care Home 25 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9), of places Physical disability (25), Physical disability over 65 years of age (25) Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. PD Minimum age 60 years Date of last inspection 9th February 2006 Brief Description of the Service: Standon Hall is a care home providing personal and nursing care and accommodation for up to 25 service users over the age of 65 years. The home also provides care for up to 2 service users with dementia (over the age of 65 years) and care, including nursing care, for up to 25 service users with physical disabilities over the age of 65 years. A private company known as Standon Hall Home Ltd owns the home. The home is located on the outskirts of the market town of Eccleshall in Staffordshire. The home is located in the countryside and is not close to shops, pubs or other conveniences. The home was built as a stately home several years ago and was first registered as a nursing and residential home on 6/3/96. Service users are accommodated on two floors. The home also has an attic and cellar area. The home has 19 single rooms and 3 double rooms. There is a passenger lift. The home has extensive grounds and gardens, which are well maintained and accessible. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by two inspectors and took four hours to complete. The inspection had been planned with information gathered from the CSCI database, the Pre-Inspection Questionnaire that had been completed by the provider and comment cards received from residents, relatives and GPs. The key standards were assessed using evidence gathered from the pre inspection information and from this field visit. The methods used to acquire the evidence at this visit included: Direct observation of care given to residents Discussions with staff members Discussions with residents and visitors Examination of relevant documents and records A walk around the home including a visit to the kitchen Observation of the lunchtime meal Discussions with the manager During the inspection, the Estates Manager and the Fire Safety Officer were also present as they were meeting to assess the fire safety at the home. The Fire Safety Officer gave feedback at the end of his visit and highlighted areas where the home needed to improve. At the end of the visit verbal feedback was given to the manager. Inspectors highlighted areas where improvements had been made as well as areas of weakness where requirements were left for improvement. What the service does well:
Case tracking of three residents identified that personal and nursing needs were being met by the staff in the home on a continuous basis Comments received from residents confirmed the above with words such as “excellent” being used to describe the home. The maintenance of independence was evident with examples of care being planned and delivered so as to promote independence, privacy and autonomy. One resident commented “I am independent because I want to be and the staff respect that.” This resident went on to say, “Privacy is very important to me but I have no issues with that.” Another resident commented that he “likes to go out in his electric chair and keeps as independent as possible.” Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 6 The home is situated in a rural setting with extensive grounds and views over the surrounding countryside. This provides peace and tranquillity for the residents who appreciate this kind of setting. One resident commented, “I like to walk around the grounds. There are lovely views and I would like to come back again.” In conjunction with the above, the home caters for equality and diversity. There are equal numbers of male and female residents welcome to come and stay at the home. The home is registered to care for elderly residents with differing degrees of physical disability and aids and adaptations were evident throughout the home. The providers had recently installed a ramp at the front entrance to the home so that wheelchair users could access the grounds easily. This had made such a difference to one resident, in particular, who used to have to use the rear entrance next to the kitchen to access the grounds. Residents are sometimes referred to the local Rehabilitation Centre at Stone to help with improvement to mobility following an assessment by the occupational therapist. Spiritual and religious needs are catered for with Church services held monthly in the home. These individual needs are documented in care plans. It was identified that one resident was Roman Catholic and there was no evidence of this lady having received a visit from the Priest despite her request for this. The manager stated that this would be arranged for her without delay. The activities co-ordinator has worked at the home for many years and there was evidence, through examination of her records that she caters for individuals with differing needs and abilities. Those residents who do are unable to join in with communal activities receive one-to-one attention from her in the privacy of their own room. The home is registered to accommodate up to 2 residents with dementia. There was evidence gained, throughout the inspection, that staff receive training in this area and are able to offer the care and support needed to individuals and their families affected by dementia. All residents are encouraged to socialise dementia needs. This works well at the home as it was observed some residents were enjoying helping others. The home does not accommodate individuals who have severe degrees of dementia or challenging behaviour. The Company’s other home - “The Beeches” adjacent is registered to accommodate individuals with these needs. What has improved since the last inspection?
It was pleasing to note that all but one of the requirements from the previous inspection had been addressed.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 7 There was evidence of improvements in relation to the delivery of care and care plans and residents commented that they felt “safe and well cared for”. There was evidence of some improvements to the quality and presentation of meals and adequate provision had been made for residents requiring soft diet. There was evidence of some improvements to the environment and the requirements had been addressed in this area. New carpets and flooring had been installed. The problem with the water tanks had been addressed. Central heating had been installed in bedroom 17. Locks had been provided for residents bedroom doors so that individuals would have privacy as and when they wished. These were of the type recommended by the fire safety officer. The problem of maintaining sufficient hot water had been rectified with the addition of pumps on tanks. Advice had been sought from the fire safety officer in relation to all the building. The fire officer’s visit was taking place at the same time as the inspection. Staff had received regular update training sessions in fire safety and this was recorded. The home appeared cleaner and tidier than previously and the domestic staff are to be congratulated on this. The staff moral had improved and both staff and residents seemed more contented. This was due, directly to the stability of the management in the home. The Registered manager was now settled into her role and she was very well supported by the clinical manager. Both of the managers were well liked by residents and staff. Positive comments were received in relation to the managers including “they are both approachable” and “if I had any worries I could go to either of them”. The Registered manager had brought about some positive changes resulting in improvements to the quality of life for the residents who live there. What they could do better:
Some disappointing comments had been received from the GP and these highlighted areas where there is a need for improvements. Areas of weakness included poor communication on occasions; there is not always a senior member of staff to confer with.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 8 The GP is not always able to see residents in private. The staff do not always demonstrate a clear understanding of service user needs. The overall comments received in respect of the quality of food and the meals presented were that this had improved. However, comments made by some individual residents indicate that there is still some need for further improvement in order to ensure that each resident receives their preferences. The presentation of the environment, although slightly improved in areas, was still in need of redecoration and refurbishment. The kitchen would benefit from repainting and the purchase of more equipment. A redecoration and refurbishment programme is required from the providers by the CSCI. Although overall staff training had improved at the home recently, this did not include NVQ training in Care and this should now be introduced in order to equip the care staff with the skills they require to meet the continuing and changing needs of the residents. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 9 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. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 10 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 Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 11 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 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are given sufficient information about the home and are able to make an informed decision on whether this home can meet their assessed needs. There are some areas in need of further improvement which have been identified throughout this report, suggesting that not all individual needs are fully met. EVIDENCE: A random sample of three individual care plans was examined. These formed part of the case tracking and identified that pre admission assessments are carried out on all individual residents before they are offered a placement at the home. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 12 Discussions with the Registered Manager confirmed that she usually carried out these assessments prior to admission. In her absence, the care manager will do this. The Statement of Purpose and Service User Guide provide information about the home. These are available to placement officers and prospective residents and their families. The previous inspection report is also available to read at the home. The manager stated that prospective residents and their families are welcome to come and visit the home and have a look around before admission. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 13 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents felt safe and well cared for and personal and nursing care was delivered with dignity and respect. The GP has raised some concerns, which need to be reviewed and addressed by the manager. EVIDENCE: Following the case tracking of three individual residents, examination of individual plans identified that their personal and nursing needs were being planned and subsequently met on a continuous basis. Discussions with these individuals confirmed the above and, without exception, all of the residents spoken to felt very happy with the care they were receiving in the home. There had been a recent audit of individual plans and areas highlighted as requiring attention had been addressed. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 14 Discussions with the residents identified that they received the care as set out in their individual plans. One resident commented that she felt “safe and well cared for” another thought that the home was “wonderful”. Comments received on comment cards read –“Staying for respite care. Staff good. Food good. Like to walk around the grounds. Lovely views. Would come back again”. Another comment stated that staff respect their dignity and “always knock on the door before entering”. When asked whether dignity and privacy were upheld at the home all of the residents spoken to confirmed this and commented that the staff treated them with “respect”. One lady stated that she could have a bath or a shower as many times during the week as she wanted. The same lady stated that she felt it important to maintain her independence and that she had been enabled to do so by the staff at the home. The GP comment card was returned to the CSCI and raised the following concerns – There is not always a senior member of staff to confer with. The GP is not always able to see residents in private. The staff do not always demonstrate a clear understanding of the care needs of residents. The GP has received complaint/s about the home in the past. The GP is not satisfied with the overall care provided to residents in the home. The following positive comments were also included on the GP comment card The home usually communicates clearly and works in partnership with the GP. Medication is usually appropriately managed at the home. Management usually take appropriate decisions when they can no longer manage the care needs of the resident. The medication records relating to the three individual residents were examined and found to be in order. The nurse was observed administering medication to the residents at lunchtime. This was carried out professionally and according to medication procedures. A medication audit had been carried out recently. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 15 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. The social and spiritual needs of residents were generally met at the home. The quality and choice of meals presented to residents had improved overall since the last inspection but there were still areas highlighted by residents for improvement here. EVIDENCE: Activities within the main house were recorded in a somewhat haphazard method. At the time of the inspection the activity person was not available to provide accurate records. Each week the complex had various activities. The care manager informed the inspectors that another activity co-ordinator had been employed. Individual spiritual needs were met by regular visits from denominational visitors. Case tracking highlighted that one of the residents did request a personal visit from the Roman Catholic priest; who visits the home. The care manager will address this. The recent residents meeting records were provided, they were limited in their scope of issues raised.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 16 At the time of this inspection no visitors were evidenced to be visiting. The inspectors were aware from other visits that families were welcome to visit freely. The meal of the day was well presented, resident’s comments were positive. The staff were observed taking meals to residents who chose to remain in their rooms. These trays were covered in an acceptable manner to transport food. Menus were seen for the week of the inspection, with the exception of when a roast dinner was served and alternative would not generally be prepared. One resident chooses to have the cooks home made fish cakes on a regular basis. These were observed in one of the freezers. The menus offered a balanced dietary content. Comments received on comment cards from residents in relation to the meals served included the following – “I am unhappy with the food”. “We get too many vegetables on the menu – they are very nice but do we need them everyday?” “If I don’t like what is on the menu I will ask for something else like sausages. This is usually done. Ian is very good.” “Sometimes food is served on a cold plate but the food is good.” During the tour of the kitchen the inspector identified that one of the fire doors was held open with a “bollard” this is unacceptable. During the inspection the fire officer visited by arrangement and gave his professional opinion of how to resolve the issue. Fire doors should not be held open at any time. The homes estate representative took on board the advice. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 17 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 systems in place help to protect residents from harm and enable them to raise concerns should they have any. EVIDENCE: There was a clear and accessible complaints procedure in place at the home. The Registered Manager stated that she takes all concerns and complaints seriously and addresses them according to the procedure. She maintains a complaint log, which was seen by the inspector. The CSCI had not received any complaints directly about this home since the last inspection. As part of the case tracking three residents were spoken to and all of them confirmed that would know whom to approach should they have any concerns. One of the residents comment cards included – “I would speak to Vincent (Clinical Manager) if something minor was upsetting me. I would speak to Bev (Manager) if it was something major. No complaints to report up to now!” Staff spoken to confirmed that they were aware of the need to monitor the safety of the residents and to protect them from any form of abuse. This was part of the training programme provided by the management, which was seen documented in the training records. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Although standards of cleanliness had improved, the home needs to undergo a redecoration programme in order to provide residents with a pleasant, homely environment in which to live. EVIDENCE: A tour of the home was conducted where all communal areas and most of the bedrooms were examined. Bedrooms sampled were identified to have numerous personal possessions around the room and bedrooms for the majority of the residents, were well over the required size. The wallpaper was dated and for some bedrooms dull, making the room darker than necessary. Previous requirements to replace carpets and flooring had been addressed.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 19 There is a need for this home to be redecorated in many areas and it is a requirement that the CSCI is supplied with an action plan outlining a redecoration programme. This was discussed with the Manager and Estates Manager at the time and it was agreed that this would be forwarded to the CSCI by 24/6/06. Bedroom doors did not have a locking facility. The inspectors were told that the manager had received today a collection of locks for the bedroom doors. Within the shower room there was an urgent need to box in the water pipes to prevent an accident to residents and staff. The bathroom on the first floor (16) did not have a working lock. The standard of cleanliness had improved since the last inspection. Two of the freezers in the kitchen area required replacing as the seals had become ineffective due to age enabling them to seal correctly.. The inspector had concerns as to the condition in some parts of the kitchen where paint was peeling off the walls. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 20 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 was adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff provided were found to be sufficient to meet the needs of the residents at the time of the inspection and although staff training was underway the skills of the staff would be improved with further development of NVQ training in Care. EVIDENCE: At the time of the inspection there were 20 residents accommodated in the home. 10 of these residents were receiving nursing care. There was a Registered General Nurse on duty throughout each 24-hour period and care assistant support was adequate to meet the needs of the residents at the time. Domestic staff were observed cleaning the home and it was noted that the standard of cleanliness had improved since the last inspection. There was one chef on duty in the kitchen, cooking for both homes and two kitchen porters supported him – one for each home. There was a full time administrator on duty, dealing with accounts for both homes. There was a full time maintenance person on duty, again covering both homes. The Manager was employed as Registered Manager for this home and General Manager for both homes.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 21 A clinical manager, who was not on duty at the time of the inspection, supported the manager at this home. There was a part time activity co-ordinator employed at the home. The staffing rota was examined and found to be in order at the time of the inspection. Comments received on comment cards from relatives included – “Too many staff with poor English making communication difficult at times. Staff cover over weekends always seems at bare minimum and carers are also expected to do kitchen duties if there are no available kitchen staff. Carers do not appear to have time and sometimes the inclination to engage residents in conversation.” Another comment read – “I visit the home monthly. Standon hall compares favourably to other homes. The staff are always around and seem friendly.” It was identified that NVQ training in direct care needs developing further and It is recommended that NVQ training is offered to suitable candidates so that the overall skill mix of staff at the home can be improved. A selection of staff files were examined and these were found to be in order at the time of the inspection. Some staff training had taken place since the last inspection. This was mainly related to health and safety training such as moving and handling, fire safety, infection control, first aid and food hygiene. There had been other needs specific training such as pressure area care, care assessing and planning, customer care and dementia awareness. Training records were examined and staff spoken to confirmed the training that they had received. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The stability and effectiveness of the management at the home is ensuring that the home runs smoothly and in the best interests of the residents who live there. EVIDENCE: The stability of the management at the home had been achieved and it was pleasing to see that the Registered Manager had settled well at the home. The Registered Manager had been assessed by the CSCI as having the necessary skills and expertise to run this home. Staff and residents spoken to were complimentary about the Manager and confirmed that she was approachable and supportive. The Manager was also supported by a Clinical Manager who, in turn, had worked at the home for several years.
Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 23 The Manager stated that she was going to be undertaking team leader training, along with the clinical managers and domestic manager. It was observed that the consistency of the management at the home was having a positive effect on the staff team and subsequently the residents felt comfortable and secure. The management was addressing quality assurance at the home. Audits had been carried out on individual care plans, medication, meals and health and safety. The home had achieved ISO 90001-quality award with no requirements made. The CSCI receives a monthly report from the Regional Manager as per Regulation 26 requirements. Staff spoken to stated that they were receiving formal supervision and records were seen to confirm this. Records were examined in respect of servicing and maintenance of equipment at the home and these were found to be in order. Fire safety in the home was being assessed by the County Fire Safety Officer at the time of the inspection and he was accompanied by the Company Estates Manager Mr Parker. Feedback was given to Mr Parker and the Manager following his inspection where some suggestions and requirements were left to be addressed. Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 24 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 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 2 3 2 2 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 x 2 Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 25 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 OP15 Regulation 16(20(i) Requirement The home must evidence that residents are generally satisfied with the standards of meals served and that individual dietary needs and preferences are catered for. This was in relation to comments received from residents and their relatives. The CSCI must receive a redecoration plan for the home from the providers. This must include timescales. The water pipes must be boxed in within the shower room identified at the inspection. There must be evidence to identify that individual spiritual needs are being met by the home. This was in relation to the resident asking for a visit by the Catholic Priest. The 2 freezers identified as required replacing (as the seals had become ineffective due to age), must be replaced. Timescale for action 20/07/06 2 OP19 23(2)(d) 20/07/06 3 4 OP38 OP12 13(4) 12(4)(b) 20/07/06 20/07/06 5 OP19 13(4) 20/09/06 Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 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 2 3 Refer to Standard OP8 OP28 OP19 Good Practice Recommendations The concerns raised by the GP should be reviewed and addressed by the manager. NVQ staff training in direct care should be further developed. The kitchen would benefit from redecoration Standon Hall Care Home DS0000022376.V296589.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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