Inspection on 09/02/06 for Standon Hall Care Home

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Standon Hall Care Home 24/05/06

Standon Hall Care Home 22/08/05

Standon Hall Care Home 22/03/05

Standon Hall Care Home 02/08/04

Standon Hall Care Home 01/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Standon Hall Care Home Standon Nr Eccleshall Stafford Staffordshire ST21 6RA Lead Inspector Mrs Yvonne Allen Unannounced Inspection 9th February 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.V284155.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 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.V284155.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Minimum age 60 years Date of last inspection 22nd August 2005 Brief Description of the Service: Standon Hall is a care home providing personal and nursing care and accommodation for up to 28 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 28 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. It is in the middle of 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 14 single rooms, 2 with ensuite facilities and 7 double rooms, 5 of which are ensuite. There is a passenger lift. The home has extensive grounds and gardens. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over four hours. The Registered Manager was not on duty at the time and inspectors met with the Care Manager who was the nurse in charge. Discussions were held with staff, residents and a visiting relative. A tour of the home was conducted during which all communal areas and a selection of bedrooms were inspected. Not all standards were assessed at this visit but those not assessed last time and those not fully met previously were examined. Feedback was given to the Care Manager at the end of the inspection and requirements were left. A letter of serious concerns was sent to the provider following this inspection and this is highlighted in the report. Between inspections a follow up visit was made to this home and a meeting with the providers was held in November 2005. What the service does well: What has improved since the last inspection? Care plan reviews had become more regular and there was evidence of participation by residents and representatives. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 6 Staff morale had improved with the consistency of the management as had staff training and support. The delivery of personal and nursing care had improved with some very positive comments received from a relative and residents. The provision of a ramp outside the front entrance had improved the quality of the life for one particular resident and no doubt others to come. 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. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 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 Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 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): 1,2,4 and 5 Prospective residents, representatives and placing officers are able to make an informed choice about moving into the home. It was identified that not all individual needs are fully met on a continuous basis and there is a need for improvement in some areas. EVIDENCE: The information published by the home for the benefit of prospective residents was perused at length, and was found to include all those details required by the standard. There was satisfactory information of the running, staffing, and management of the home, together with details of the services provided for the categories of patients/residents, for whom they were registered. The management structure of the home together with how to express a concern or complaint were both fully covered, as was the restriction placed upon where a resident may or may not smoke. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 9 The contracts observed in a random sample of residents care plans set out details of the room occupied, what was covered by the total care fee and what services would incur an extra charge, the terms and conditions including protocols for early termination of the contract and grounds that might trigger these, and the arrangements being set up for the payment of fees including who shall be responsible for making the payments, social services, the resident themselves, a relative, or a solicitor or some other financial advocate, either informally appointed or under the legal framework of the Court of Protection,[Receivership, or Power of Attorney]. The home actually had a policy covering trial visits [B 0401] that clearly set out the importance of a prospective resident having the opportunity to meet both staff, and existing residents before taking any decision to move into the home. Where this was not advisable due say, to the individual being in hospital and extra journeys felt to be counter productive to their well being, the home recommended that a close family member or friend should visit on their behalf, and tell them about what they had seen, and their feelings about the home based on their visit. Discussions with a resident and his visitor identified that, whilst they were very happy with the personal and nursing care provided by the staff, they were dissatisfied with the standard of the food served at the home. They were also unhappy with heating arrangements in the bedroom, saying that it was often not warm enough. Two other residents spoken to whilst they were eating their lunches also stated that they were unhappy with the standard of meals provided at the home. Care plan documentation did not always reflect the specific care delivered to individuals and could therefore not evidence that individual needs were met on a continuous basis. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 10 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 and 11 Care plan records will need to be more specific in order to reflect actual care delivered. Individuals could be assured that they and their families would be treated with dignity and respect at the time of their death EVIDENCE: In the care plan of one resident, which was reviewed following discussions with him about whether the concerns he raised at the previous inspection of 22/08/05 had been met, it was found that there was no record of his request to occasionally have an egg for breakfast, even though this choice was relayed to the manager by the inspectors at that time. In other care plans reviewed at random, continuous use of stock phrase entries were evident, especially, “Appears to have slept well”, leaving inspectors unclear as to whether any checks had been made during the night, and therefore any care given. There was no written evidence in the plans that these residents had requested not to be checked on during the night. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 11 In the case of one lady, the inspector was particularly concerned, as elsewhere in the plan it stated that she was unable [of her own volition] to maintain a safe and secure environment. Finding a fire exit in her room, with the “Break glass” already broken, and the door not secure in any way further magnified this concern. It lead directly to external fire escape stairs, and other entries on this lady’s file recorded a number of recent falls [thankfully without apparent injury] and the fact that at times she was disorientated and confused. Fortunately the handyman was able to replace the “Break glass” and secure the door, before the inspectors left the home, so the preparations being made by the nurse in charge to accommodate the lady in another room were not needed, but it will be a requirement of this report that the room is checked each time the lady goes to bed, to ensure the environment is safe, suitable for its stated purpose, and meets the assessed needs of the resident. The policies on care of the dying were reviewed at this time, and were felt to be sufficient and sympathetic. They included information and or direction on the procedures to be expected, care practices to be observed, referral to religious representatives for information on rites and customs associated with that denomination or sect, inclusion of the resident themselves in the formulation of their plan. Support for their family and the other residents of the home and staff during grieving was mentioned, as was the importance of establishing the arrangements chosen regarding the funeral. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 12 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): 12,14 and 15 Evidence was uncovered of choice and control not being met. Further evidence suggested that the meals served were unappealing and inflexible. There was evidence of continued contact with family members, and of attempts to provide entertainment for residents. EVIDENCE: When speaking to one resident about choice of food, the inspector was told that when he asked a care assistant if he could have an egg for breakfast, he was told he could not, so he then asked if he could have some marmalade or jam to put on the dry toast he had been brought, he was again told that he could not. At this time, the inspectors were unsure whether the male kitchen assistant was denying the resident his rightful and reasonable choice, or whether his understanding of English Language was not adequate to qualify him for the position in which he was employed, as he was not available to be interviewed at the time of this inspection. What was clear was that this resident did not consider that his meals were wholesome, balanced, or appealing, or that he was being helped to exercise choice or control over his live. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 13 Observation of the residents eating lunch identified that the main meal served consisted of two spring rolls, diced Swede and mashed potatoes. Residents spoken to were obviously unhappy with their meal and, when asked what it was they were eating, were unsure and gestured that it was not appealing. The meal served was not nutritious and there was no obvious alternative on offer. The inspector visited the kitchen and asked the cook what was on offer for the teatime meal. There was a platter of sandwiches prepared and an alternative of ravioli on toast. When asked what the residents would have with their sandwiches the inspector was told that this would be soup and then cake afterwards. There was no salad garnish or side salads available or any other savouries, which the residents might enjoy. Neither was there any choice of fresh fruit or fruit salad. It was not identified what was available for those residents requiring a soft diet as ravioli on toast was not a suitable dish for residents who have difficulty chewing and/or swallowing. It is a requirement of this report that the menus are urgently reviewed, the standard of food served improved and that individuals are offered choices and preferences and soft diets catered for. It is a recommendation that a dietician or nutritional specialist assesses the current menus. The above concerns relating to the standard of meals served at the home was raised to the provider in the form of a letter of serious concerns sent out following this inspection. Whilst reviewing care plans, the inspectors saw evidence of regular input into the lives of some residents by friends and family members, and were able to confirm with a set of visitors that they joined their relative for parties and other arranged activities organised by the home. There was reference to the hard work put in by the activities co-ordinator, but as she also covered the other registered home on the same site, there was concern that insufficient hours were allowed for the level of one to one interaction required by many of the current residents. This need arose not only from their levels of dependence making group activities inappropriate, but also from the lack of other contacts that some residents had. Thus one resident who had no family in this country, had needed the support of staff to go shopping for such essentials as replacement clothes. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 14 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): 17 There was insufficient evidence in the areas reviewed at this time to declare that the legal rights of residents were being fully protected. EVIDENCE: Staff were able to point to documentation of the appointment of an advocate for a gentleman a year ago, and there was a full page of textbook quality instructions in the homes procedures manual. Unfortunately, when the inspectors reviewed the actual care plans of real people, they could find no reference to either advocacy or the use of Power of Attorney, in spite of being led to understand that one of the residents under review had entered into such arrangements. It was equally disappointing not to find any local information about advocacy groups who operate in North Staffordshire [Men cap, Assist, Beth Johnson] available in the home. None of the staff on duty in the home at the time of this inspection were able to confirm what steps were taken to allow residents to take part in the civic process. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 15 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, 25 and 26 The standard of the décor within this home is poor with little evidence of improvement through maintenance or future planning. EVIDENCE: In the case of one lady, the inspectors were particularly concerned, to learn from her care plan that she was unable [of her own volition] to maintain a safe and secure environment, especially when seeing a fire exit in her room, with the “Break glass” already broken, and the door not secure in any way. It lead directly to external fire escape stairs, and other entries on this lady’s file recorded a number of recent falls, and the fact that at times she was disorientated and confused. Fortunately the handyman was able to replace the “Break glass” and secure the door, before the inspectors left the home, so the preparations being made by the nurse in charge to accommodate the lady in another room were not needed, but it will be a requirement of this report that the room is checked Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 16 each time the lady goes to bed, to ensure the environment is safe, suitable for its stated purpose, and meets the assessed needs of the resident. Observation of bedroom 17, which is a shared room, identified that this was not centrally heated and did not have a radiator. There was one plug in heater to warm the room. This was a large double room and the heating provided at the time of the inspection was ineffective. As the inspector sat and chatted to the resident and his relative the temperature of the room became cool and this was out of the control of the resident and/or the staff. The resident’s wife, who was poorly at the time, was nursed in bed in the same room. Inspectors went on to check the temperatures of the hot water supplied to the baths and shower and found that this was too cool-registering 32 degrees centigrade. It was also noted that there were inconsistencies in temperatures throughout the home. Whilst one bedroom was excessively warm (bedroom 23) another was too cool (bedroom 17). Discussions with the maintenance person identified that he had turned down the hot water temperature as he was trying to save what little oil he had left in the boilers. He went on to explain that he had been promised a delivery of oil earlier but that this had not arrived but he had been assured that this would be delivered later on in the day. When asked if this had happened before he confirmed that it had. During the late morning and early afternoon period it was identified that residents would be unable to take a bath or shower if they wanted to, as the water supply was not hot enough. The inspectors were informed that the oil had been delivered during the afternoon and that the temperature of the water would soon be back to normal. The above issues were brought to the attention of the provider in the form of the letter of serious concerns. A tour of the home revealed that very little had been done in the way of redecoration and refurbishment at the home since the last inspection despite a previous requirement for this. In bedroom 27 the carpet was very ruttled and posed a tripping hazard. This must be replaced. The carpeting in the corridor area outside room 26 and 30 was in need of replacement as this also posed a tripping hazard. The general standard of the paintwork on doors and skirting boards throughout the home was poor with many of these being very scuffed and grooved in places. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 17 The linen room opposite room 30 was very cluttered with two beds lying on their sides. This made it very difficult for staff to access linen without the risk of tripping over the beds. The wall in the wash hand room located in the toilet block 32 was in need of replastering and repainting. This had been raised at the previous inspection and although there was now the provision of wash hand facilities, the appearance and condition of the wall was poor. The door to the toilet which was second toilet along from the wash had room could not be effectively closed from inside the toilet thus compromising the privacy and dignity for residents using this toilet. This was pointed out to the maintenance person at the time of the inspection. In bedroom 23 it was noted that the switch for the main light was difficult to access being located down the side of the wardrobe. Also, there was no bedside lamp provided so the resident would be unable to control the lighting in this room. In fact there was a general lack of bedside lamps provided throughout the bedrooms. There was no lockable facility provided on the door to bedroom 23 so even if the resident wanted to lock the door this would be impossible. This was the case with many other bedroom doors. All bedroom doors must have the facility of a lock and, following a suitable risk assessment; residents must be offered a key to their rooms. There were some wardrobes throughout which were not attached to the walls. These were identified as being two in the corridor by room 21. One was a very large heavy wardrobe, which would topple over if pulled. The other was located in bedroom 14 by the door. These were pointed out to the maintenance person at the time. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 18 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 and 30 The residents are cared for by staff who are competent and provided in sufficient numbers to meet their needs. EVIDENCE: At the time of the inspection there were 22 residents accommodated in the home, 12 of who were receiving nursing care. There was one qualified nurse on duty working with three care assistants from 8 am – 2pm then from 2pm this number dropped to two care assistants plus one nurse and from 8pm through to 8am there was one nurse and one care assistant on duty. There was a domestic assistant working on the floor. The activities co-ordinator worked part time and covered both homes. There was a full time maintenance person employed covering both Standon main Hall and The Beeches. Ancillary and kitchen staff were employed to cover both homes. The staff-training programme had taken off at the home and there was evidence to support this with staff attending various courses. Staff spoken to stated that they felt supported with their training needs. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 19 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 and 38 The management of the home is now more settled and consistent and the residents and staff benefit from the ethos and leadership style. The maintenance of the home is weak in some areas with the result that health and safety of residents and staff is compromised at times. EVIDENCE: The manager of the home was not on duty at the time of the inspection and inspectors spoke with the care manager. The manager was now registered with the CSCI for Standon Main Hall as Registered Manager and was also General Manager over both Standon Main Hall and The Beeches (The Beeches not having a registered manager as yet). The care manager who had been appointed this role since the last inspection supported the registered manager. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 20 Comments received from residents and a visitor identified that they felt that management support was good and that both were approachable and would deal with any concerns they might have. Staff were also complimentary about the management of the home stating that this had improved and that they felt well supported. There was evidence of staff meetings and advancement with staff training. Residents/relatives meetings had also been held with minutes taken. Records and documentation were examined in relation to the maintenance of equipment at the home. The required testing and servicing of equipment had been carried out and records maintained. Inspection of the kitchen identified several pieces of equipment which was leaking and where bowls were being used to catch the leakage. These were identified as being the gas oven, the water tap between the ovens and the dishwasher. This was discussed with the cook at the time of the inspection and these pieces of equipment must be made good. Freezer number 2 was identified as having perished seals and will need replacing. In the freezer room at the far end of the kitchen corridor all the freezers were in need of defrosting and a thorough clean. The hand-washing sink located in the main kitchen was dirty. Mandatory staff training was on going at the home and there was written evidence of this. However, it was identified that three members of the care staff and one trained nurse had not had any recorded fire safety training drills for 2005. Out of four night staff (trained nurses), one had had no recorded induction and three had no recorded fire safety training. This was particularly concerning as these nurses were in charge on night duty. The previous requirement to address the alterations and improvements to the water tanks in the main hall had not yet been addressed but an action plan had been received from the providers to outline that this would be done by April 2006. Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 21 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 x 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 2 18 x 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x x 2 Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 22 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 2 Standard OP38 OP19 Regulation 23(4) 23(2)(b) Requirement All staff must receive the required fire safety training and drills and this must be recorded New carpeting is required along the corridor areas by room 30 and 26 and the flooring must be made level. Bedroom 27 requires a new carpet and the floor making level In bedroom 23 the light switch must be moved and made more accessible The redecoration and refurbishment programme throughout the home must be developed and continued without delay. PREVIOUS REQUIREMENT OF LAST TWO INSPECTIONS The wardrobes identified in room 14 and along the corridor areas must be secured to the wall to prevent them toppling over. All water tanks must be brought up to WS Reg 1999 standards or replaced. PREVIOUS REQUIREMENT OF LAST TWO INSPECTIONS The extraneous items seen stored in the linen room must be DS0000022376.V284155.R01.S.doc Timescale for action 20/03/06 20/04/06 3 4 5 OP19 OP25 OP19 23(2)(b) 23(2)(b) 20/04/06 20/03/06 20/04/06 23(2)(b) 6 OP38OP19 13(4) 20/03/06 7 OP38 23(5) 20/04/06 8 OP19 23(2)(l) 20/03/06 Standon Hall Care Home Version 5.1 Page 23 9 OP19 23(2)(b) 10 11 OP7 OP21 12(1)(b) 12(2,3,4) 12 13 14 15 16 OP38 OP26 OP26 OP38OP26 OP15 23(4) 16(2) 16(2) 16(2) 16(2)(i) 17 18 OP15 OP15 16(2)(i) 16(2)(i) 19 OP25 23(2)(j) 20 OP25 23(2) 21 OP19 23(4) removed and stored appropriately The paintwork on doors and skirting doards throughout the home must be made good and repainted. There must be evidence of the regular monitoring of residents throughout the night The toilet door to the end toilet in the block room 32 must be made so that it can be closed from inside the toilet Cigarette smoking in the toilet which used to be room 19 must cease with immediate effect. Freezer number 2 must be replaced with a new freezer The freezers mudt be thoroughly cleaned and defrosted regularly The equipment which was leaking in the kitchen must be repaired or replaced The meals served must be reviewed and residents must receive food which is nutritious, wholesome and appetising Adequate provision must be made for those residents requiring soft diet Individual residents must be offerred a choice of meals and the choices they make must be upheld The hot water must be maintained at a constant temperature so that residents can take a bath or shower at any time Central heating must be provided in bedroom 17 and the temperature of this room must be made comfortable for the resident and be maintained Advice must be sought from the fire safety officer in relation to the use of the fire door located in DS0000022376.V284155.R01.S.doc 20/04/06 20/03/06 20/03/06 20/03/06 20/04/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 20/03/06 Standon Hall Care Home Version 5.1 Page 24 22 OP7 13(4) 23 OP17 12(4) room 13. A risk assessment must be developed for the resident accommodated in room 13 in respect of her personal safety Locks must be put on to bedroom doors and individual residents be offerred a key following a suitable risk assessment 20/03/06 20/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP17 Good Practice Recommendations It is recommended that more activity hours are provided for residents at the home The details of advocacy services should be made available in the home Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 25 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 © 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 Standon Hall Care Home DS0000022376.V284155.R01.S.doc Version 5.1 Page 26 - 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. 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