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Inspection on 19/12/05 for Standon Hall Care Home (The Beeches)

Also see our care home review for Standon Hall Care Home (The Beeches) for more information

This inspection was carried out on 19th December 2005.

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

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

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

What the care home does well

Examination of care plans identified that the health care needs of individuals were met by a multi disciplinary team working together. There was evidence of involvement with other healthcare professionals and outside agencies where needed. The provision of support either by families or by advocates was evident which is so important for these vulnerable individuals.

What has improved since the last inspection?

The provision and monitoring of personal care and nursing care had improved since the last inspection. The content and evaluations of individual care plans had improved. Staff training had improved. This included mandatory training and other training relevant to meeting the needs of the residents. The general manager has overseen these changes and has been effective in bringing about the above improvements.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Standon Hall Care Home (The Beeches) Nr Eccleshall Stafford Staffordshire ST21 6RN Lead Inspector Mrs Yvonne Allen. Other inspector – Mr Berwyn Babb Unannounced Inspection 19th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Standon Hall Care Home (The Beeches) DS0000022377.V276466.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 (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Standon Hall Care Home (The Beeches) Address Nr Eccleshall Stafford Staffordshire ST21 6RN 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) 01782 791555 01782 791396 Standon Hall Home Limited Care Home 34 Category(ies) of Dementia (34), Dementia - over 65 years of age registration, with number (34) of places Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. DE over 60 years only Date of last inspection 21st June 2005 Brief Description of the Service: Standon Hall - The Beeches is a care home providing personal care and accommodation for up to 34 older people suffering from enduring mental health problems. It is owned by a private company called Standon Hall Homes Limited. The company own many other nursing and residential homes across the country.The home is located on the outskirts of the small village of Standon near to the town of Eccleshall in Staffordshire. The home is situated in a rural setting with views over the surrounding countryside. It is not within walking distance of any amenities and transportation would be required to visit the nearest village.The home was opened in 1998 and consists of two single storey buildings, which were built around 1930 as a hospital. A long covered walkway forms a corridor link between the two units.All the home’s bedrooms are single, apart from one shared room on Beeches One, with the provision of a sink. Bathing and toilet facilities located near to bedrooms. The home is situated opposite the Standon Hall Care Home with Nursing (general). This was previously a stately home and the two homes share the spacious grounds. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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 over four hours by two inspectors. A tour of both units was undertaken where all the communal areas and a selection of bedrooms were inspected. Inspectors met with residents and staff and chatted to the nurse in charge, various staff members, including a senior care assistant and some of the residents. There were no visitors present at the time of the inspection. Relevant records and documentation were examined and lengthy discussions were held with the general manager. Verbal feedback was given at the end of the inspection. Not all of the standards were inspected on this occasion, only standards which had not been assessed at the last inspection plus those which had scored less than three last time. There is an urgent need to address the statuary requirements partially those made on previous inspections. Continued inattention to these could lead to enforcement action being taken against the provider if on the next visit these have not been addressed within the given time scale. What the service does well: Examination of care plans identified that the health care needs of individuals were met by a multi disciplinary team working together. There was evidence of involvement with other healthcare professionals and outside agencies where needed. The provision of support either by families or by advocates was evident which is so important for these vulnerable individuals. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 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. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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 (The Beeches) DS0000022377.V276466.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): 3,4 and 5 Residents and their representatives are supplied with information before entering the home and pre-admission assessments are carried out. There was evidence that personal and healthcare needs of individuals are met. However, the provision of social and therapeutic activities for individuals in the home is severely lacking. These needs are not met and the programme of activities offered is ineffective. EVIDENCE: In three of the care plans chosen at random to assess compliance with the standards, the resident had been initially admitted as an emergency, before being later reviewed and offered a permanent place in the home. For this reason none of them had made a pre-admission visit, but their records showed that they had been visited by a senior member of staff to assess their needs and tell them about the Beeches, and that one or more of their relative/supporters had visited the home to form an opinion as to whether it would be suitable for them or not. Other care plans of more recent admissions Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 9 identified that pre-admission assessments were undertaken before residents were admitted. On each file there were copies of Community Care Assessments which had been undertaken to determine the level of independence/dependence of each resident prior to their admission to the home, and these were enhanced by the assessment of the member of staff who had visited the individual in hospital, to see that the home was able to meet their care needs. None of the residents whose files had been picked were able to confirm this in conversation with the inspector, due to the severity of their Dementia limiting their cognitive ability. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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, 8. 9, 10 and 11 Care plans need to be better organised in order to be more effective. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The poor environment and lack of homely comforts does not lend itself to the promotion of dignity for individual residents. EVIDENCE: The care plans reviewed contained not only basic assessments, but ongoing and developing information about the health and personal needs of the resident, and also a growing record of what their choices were, based where possible on their expressed views, but mainly deduced from their responses to daily events and stimuli, together with information gleaned from relatives about their pre-morbid likes and dislikes. An example being where a gentleman preferred not to be called by his first name, or another who had stated that when their life ended, they wanted a simple graveside service rather than one in a Church. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 11 Two of the plans needed a good reformulating, as care plan numbers in the index did not correspond with the placing or numbering of that individual plan. The new general manager of the site has commenced this work, but unfortunately not all of the care plans have yet benefited from her auditing and overhauling input. One plan in particular actually contained two statements made at different times, that were diametrically opposed to each other, one that the resident [who had a chronic mental illness], was not capable of giving consent, and then a later opinion that she was. Perhaps the fullest and most comprehensive part of the care plans was where they related to the health needs of resident’s, and how these were being met. There were details of input from relevant primary, secondary, and tertiary health professionals. A Physiotherapist had been engaged to assess for a resident’s mobility needs, and the provision of a suitable aid [in this case a wheel chair] had been arranged through the proper channels, and to the individual specification measured for that resident. Dentists, Chiropodists, and Opticians were recorded as having visited, as had hearing aid specialists. There were the usual and expected entries made by G. P‘s, C. P. N’s and District nurses, together with input from a continence advisor, and the Stone Rehabilitation Centre. There were charts to indicate regular monitoring of food intake and fluid balance, and a record of any falls sustained, together with the action taken to try and redress this. [Review of medication in one instance, more detailed monitoring by staff in another]. Each file had a matrix of regular “Well Being” checks covering such things as; Pressure Areas, Malnutrition Universal Screening Tool, Body mass index, current situation regarding individual risk assessments, bowel movements, personal hygiene, behavioural problems requiring restrictive intervention [either pharmaceutical or physical restraint], temperature, and blood pressure. No resident was assessed as being capable to manage his or her own medication. The only residents able to express an opinion said they were well treated, and observation showed the attitude of staff to be well intentioned. Evidence for a proper regard for the wishes and treatment of the individual as regards dying was found in one care plan where the desired arrangements following death had been very clearly recorded. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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, 13, 14 and 15 Efforts were being made to ensure the nearest match to daily activities, lifestyle, contacts with significant others, and choice of diet, as could be achieved with this group of severely disadvantaged residents. This task was not being achieved effectively and would have been made easier by employing sufficient appropriately trained staff. EVIDENCE: Given the extreme limitation of most of the residents, the frugality of the activity organiser input at the Beeches, was of concern to the inspectors. Most residents would only benefit from personal one to one intervention, and the current number of hours afforded to dedicated activity staff was wholly inadequate for the needs of the residents of the Beeches. The number of activity hours allocated to this home had been increased since the last inspection, but inspectors were informed that there was a problem in the recruitment of appropriate activities staff. Regular contact, and management of contact, with family members was seen in two of the care plans reviewed, unfortunately, another resident had no known contacts, having spent many years in an isolated institution before Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 13 coming to the Beeches. To the credit of the home, an advocate had been arranged to fulfil some of the functions normally undertaken by relatives. One of the ways that staff stated they were able to promote choice with residents, was to offer alternatives whenever possible. This may have been by taking them to their drawers and wardrobe when they were dressing, so that they could indicate which clothes they wanted to wear, or by having plates containing different meals in each hand, so that they could chose and eat their food, before they had forgotten that it was what they had wanted. The provision of diet and weight charts and nutritional screening data in care plans has already been commented upon, and in one plan a resident’s preference for sandwiches was clearly recorded. Likewise, in other plans favourite foods were mentioned, as were strategies to maintain a healthy body mass, something that is a particular problem for people with Dementia, who may either be unable to sit still long enough to eat a plated meal, or who may be experiencing difficulty in swallowing and need a soft diet, or who may think they have only just finished the meal they are remembering from years past. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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 evidence of the rights of residents being protected, even if they were unable to exercise such rights personally due to their limitations. EVIDENCE: The inspectors engaged in a deep discussion with the care manager of the main hall [the Beeches does not currently have a registered care manager] regarding the legal status of one residents attorney, and found her well versed in the difference between informal advocates, and those acting through The Court of Protection Power of Attorney, either Enduring, or without enduring powers. Discussion with other members of staff showed that postal votes were obtained for residents at the home, even if nobody could remember anyone ever exercising that right. Evidence contained in one of the care plans reviewed demonstrated that independent organisations had been approached to provide advocates to assist residents in specific tasks, especially where there was no family to support them. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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, 20, 21, 22, 23, 24, 25 and 26 The environment provision for these residents is poor and is not homely. Basic comforts are lacking and the cleanliness of the environment is poor in relation to infection control. EVIDENCE: A tour of both units was undertaken starting with Beeches 1. The carpet at the entrance to this home and in the lounge and dining room had started to look dirty and stained again and are in need of deep cleaning or replacement. The windows throughout both units were dirty and in need of a thorough clean. This has been noted on previous inspections and it would seem that the arrangements for the cleaning of windows at this home is ineffective. In the kitchenette, it was noted that there were foodstuffs left uncovered and undated. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 16 For fire safety and evacuation procedures, advice should be sought from the fire safety officer in relation to having resident’s names put onto bedroom doors and a list of residents names maintained within easy reach which identifies which bedrooms residents are accommodated in. The standard of the headboards to some of the beds throughout both units were unacceptable with these having been in place for many years. An audit must be undertaken with replacement of these headboards. The main entrance to Beeches 2 is now at the front of the home and this is a great improvement. The reception area is pleasantly decorated with seating available and the staff are able to monitor the coming and going of visitors to the home. There is a secure door, which has a coded lock for entrance and exit. Inspection of bedrooms on Beeches 2 identified that there was a very strong smell of urine in room 2 which could be smelled from the corridor area. The carpet in this bedroom must be replaced as a matter of urgency and the odour must be eliminated. It was also noted that there was no privacy afforded to this bedroom as the entrance to the home overlooked the window. Attention must be given to this by the provision of blinds. The carpet along the corridor area by bedrooms 22 and 23 was ruttled with a raised area. This posed a tripping hazard for both residents and staff and this must be eliminated. The bathroom nearest to the kitchenette is dull and uninviting and in need of making more homely. The tables and chairs in the dining room on Beeches 2 were unstable and unsafe and must be replaced. At the time of the inspection the kitchen porter was wiping down the surfaces in the kitchenette in Beeches 2. Inspection of the refrigerator identified that this was switched off with foodstuffs still inside. When this was pointed out to the porter, who did not have a very good understanding and/or command of the English language, he had not realised that the fridge was switched off, although this must have happened several hours previously as the ice had melted in the freezer box. The fridge was dirty and, when plugged in the light was not working. Some of the seals were starting to wear. This fridge must be replaced. The general cleanliness of the kitchenette was unacceptable. The cleanliness of the environment has been identified at previous inspections and must be addressed. Staff must receive further training in this area and must understand the need for and importance of cleanliness in care homes. There were insufficient easy chairs to accommodate all of the residents in the lounge in Beeches 2 and some of the chairs in use were in need of Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 17 replacement. There is a requirement for another 22 new easy chairs to be provided. The previous requirement for the provision of a safe enclosed garden for the residents of Beeches 1 has not yet been addressed and must now be implemented without delay in readiness for the summer months. Standon Hall Care Home (The Beeches) DS0000022377.V276466.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, 28 and 30 Staff provided had the necessary skills to meet the needs of the residents accommodated in the home. More trained nurses are needed on Beeches 2 in order to provide cover for all the shifts and to prevent the existing nurses from becoming fatigued. EVIDENCE: At the time of the inspection there was a total of 24 residents accommodated in the home. There were eight residents on Beeches 1, with seven being in receipt of personal care and one receiving nursing care. For this there were two care staff on duty throughout the daytime and one at night. On Beeches 2 there were 16 residents receiving nursing care. There was one trained nurse on duty throughout each 24-hour period together with two care staff from 8am-8pm then one care assistant working with the nurse during the night. There was still no unit/residential manager for this home and this has now become an urgent requirement. Ancillary, maintenance, administrative and activities staff are shared between this home and the main hall next door. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 19 It was concerning to note that the nurse on duty at the time would be working long shifts over Christmas and New Year. There were insufficient trained nurses provided on this unit to cover shifts appropriately with the result of the two remaining nurses having to cover all the shifts on days between themselves. Discussions with a senior care assistant and the nurse in charge identified that there was a staff training programme in place and that staff felt supported by the general manager of the home. The care assistant was now a moving and handling trainer after having completed a “training the trainer” course. She had also undergone training in Dementia Awareness and Managing Challenging behaviours. Other training undertaken had included the promotion and management of continence and mandatory updates of fire safety and food hygiene, POVA, infection control and first aid. She had attended two fire drills so far this year. The registered nurse stated that she had been employed in October and had undergone some induction training. However, she had not yet had a moving and handling update or had attended a fire drill. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 20 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, 35, 36 and 38 A registered manager is needed for this home to oversee the delivery of care and give staff the on going supervision required. EVIDENCE: The staff at the home felt very supported by the general manager and there was evidence that this manager was making improvements to the provision of care at the home. Both members of staff spoken to were complimentary about the general manager. The nurse on duty identified that she felt that the provision of a clinical manager to the home is what was needed without further delay. Although she had support from the general manager, she herself was a general nurse and had had very little mental health training and felt somewhat out of her depth. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 21 Formal staff supervision had commenced but care staff had not received six supervisory sessions as required and this must now be developed further so that all care staff receive adequate help, support and supervision. The requirement for the provision of a registered manager at this home has now become one of urgency. The regional manager completes regulation 26 monthly monitoring reports and sends these in to the CSCI. Other forms of auditing have included an audit of the care plans, medication and a residents/relatives meeting. An environmental audit is required to help identify areas in need of improvement and to implement a programme of refurbishment in order to improve the standard of the environment for the residents who live there. The inspector met with the recently appointed administrator. She had settled in and appeared to be working effectively in her role. The administration office has now moved downstairs which has been an improvement. The administration and maintenance of residents’ finances was examined and found to be in order. The files relating to the pocket monies of two residents were checked and these had been maintained as required. There is a recommendation that two signatures are obtained when monies are received into and taken out of individual accounts. Records were examined in relation to the maintenance of the home. The new maintenance person had settled in and maintained good records relating to the required testing and servicing of equipment. Discussions had been held with the providers at a meeting in November in relation to the state of the water tanks and work on these tanks, which had not been undertaken. The Commission had sought further advice from the Health and safety Officer in relation to this and the work on the tanks must be undertaken by the date agreed with the provider and as laid out in the action plan for the home. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 22 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 x 3 1 x 2 Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 7 Regulation 15(1) Timescale for action Care plans need to made clearer, 20/02/06 be better organised and must not contain contradictory or conflicting information. The social and therapeutic needs 20/02/06 of residents must be met. PREVIOUS REQUIREMENT The carpets in the lounge, dining 20/02/06 room and entrance area to Beeches 1 must be thoroughly cleaned or replaced. The carpet along the corridor 20/01/06 area by rooms 22 and 23 in Beeches 2 must be made safe Windows throughout the units 20/02/06 must be kept clean A new refrigerator must be 20/02/06 provided for the kitchenette in Beeches 2 and the temperature of the fridge must be recorded daily. Foodstuffs must be covered, 20/01/06 labelled and dated whilst stored in the fridge An audit of the environment 20/02/06 must be undertaken and this must include replacement of the worn headboards on the beds. The smell of urine in bedroom 2 20/01/06 DS0000022377.V276466.R01.S.doc Version 5.1 Page 24 Requirement 2 3 12 26 16(2)(m)( n) 23(2)(d) 4 5 6 19 26 26 13(4)(a) 23(2)(d) 16(2)(j) 7 8 26 19 16(2)(j) 23(2)(c) 9 26 16(2)(k) Standon Hall Care Home (The Beeches) 10 19 16(2)(c) 11 12 13 19 19 19 23(2)(c) 23(2)(c) 23(2)(o) 14 26 16(2)(j) 15 16 31 and 32 30 and 38 8 and 9 23(4)(e) 18(c)(i) 17 18 36 38 18 (2) 16(2)(j) on Beeches 2 must be eliminated The provision of blinds or other suitable window covering must be provided in bedroom 2 Beeches 2, following a suitable risk assessment New dining tables and chairs must be provided for Beeches 2 22 new easy chairs must be provided in Beeches 2 lounge A safe, accessible enclosed garden area must be provided for the residents of Beeches 1 PREVIOUS REQUIREMENT The general cleanliness of the kitchenette areas must be improved upon and staff must be adequately trained A registered manager must be provided for The Beeches PREVIOUS REQUIREMENT The staff induction procedure must ensure that all staff, including registered nurses, undergo a fire safety drill and moving and handling update training within the first 6 weeks of employment Formal staff supervision must be further developed and documented Work on the water tanks must be carried out as agreed PREVIOUS REQUIREMENT 20/02/06 20/02/06 20/02/06 20/04/06 20/02/06 20/02/06 20/02/06 20/02/06 01/04/06 Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 25 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 27 35 19 and 38 Good Practice Recommendations That more trained nurses are employed on The Beeches in order to cover all of the shifts so that staff working these do not get over tired. Two signatures should be obtained when dealing with residents’ monies. For fire safety and evacuation procedures, advice should be sought from the fire safety officer in relation to having resident’s names put onto bedroom doors and a list of residents names maintained within easy reach which identifies which bedrooms residents are accommodated in. Standon Hall Care Home (The Beeches) DS0000022377.V276466.R01.S.doc Version 5.1 Page 26 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. 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