Inspection on 02/05/06 for Standon Hall Care Home (The Beeches)

This inspection was carried out on 2nd May 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.

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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 (The Beeches) Nr Eccleshall Stafford Staffordshire ST21 6RN Lead Inspector Mrs Yvonne Allen Key Unannounced Inspection 2 May 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Standon Hall Care Home (The Beeches) DS0000022377.V292267.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.V292267.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.V292267.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. DE over 60 years only Date of last inspection 19th December 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 – Beeches One and Beeches Two. 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. This was previously a stately home and the two homes share the spacious grounds. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was planned prior to the inspection visit held on 2nd May. The visit was planned and organised so as to gather evidence across the key standards. There had been an additional visit made to the Home since the last inspection and an action plan had been received from the providers in response to this. A second additional visit made a few days later confirmed that requirements had been addressed. The CSCI did not receive any relatives/visitors and service user comment cards prior to this inspection but some were received just after the visit and their comments have been included in this report. A comment card was received from the GP and a letter from a Social Worker prior to the inspection. The following methodology was used to gather evidence: Direct observation of delivery of care and services, Discussions with residents, relatives, staff and management. Examination of relevant records and documentation, Case tracking of three residents, Tour of communal areas, external grounds, a selection of bedrooms and the kitchen. At the end of the inspection verbal and written feedback was given to the General and Regional Managers. Some immediate requirements were left and other requirements have been generated in this report. On arrival at the home Beeches 1 was closed for the day and the residents were being nursed on Beeches 2. The inspectors were told that this was due to work being carried out on the water tanks on this unit. Workmen were evidenced on site during the visit. There were sufficient numbers of staff on duty at the time and most of the residents were accommodated in the main lounge area on Beeches 2. Staff were attentive to residents and appeared to have a good rapport with them and each other. Later on in the afternoon the activity co-ordinator arrived and supervised some activities after speaking with the inspectors. There are some very skilled and caring staff at this home whose dedication to the home and the residents goes without question. However, the home does employ a high number of staff from overseas and this can cause a problem with communication at times. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 6 The remainder of the summary highlights that, although there have been minor improvements, this home is failing to meet many of the minimum standards across different outcome areas and that the Provider must initiate an improvement plan as a matter of urgency in these areas. What the service does well: What has improved since the last inspection? The standard of care planning has improved since the last inspection. Individual plans were found to be more organised, comprehensive and effective. There was more evidence of working with other healthcare professionals and reviews were thorough and informative. Case tracking revealed that care was delivered according to individual plans. The provision of outdoor facilities was improving slowly with the introduction of a safe enclosed accessible garden area for residents accommodated on Beeches 1. Some new furniture had been purchased for Beeches 2 – chairs in the lounge and new dining tables had been ordered. New carpets and flooring had been ordered for some areas within the home. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 7 What they could do better: Although there had been some small improvements to the environment this had not taken much effect internally. The home does not lend itself to creating a homely, domestic environment and there are many areas within the home that still resemble an institution. The CSCI have brought this to the attention of the provider on previous inspections and are awaiting an update/action plan from them with a view to major alterations to this home. The views of healthcare professionals were conflicting with their overall satisfaction of the care services provided. Comments from a Social Worker were positive whereas the GP comment card indicated his/her dissatisfaction with the care afforded to residents and staff communication. The CSCI are very concerned that there has been no application for Registered Manager from the providers and, as such, the home are operating outside of the care standard regulations. The General and Regional Managers confirmed that there is now an individual employed at the home who the Company are putting forward for this position. An urgent requirement has been left in respect of Manager application and this is expected to be received within the next few weeks. The home is failing to meet the social and therapeutic care needs of the residents accommodated and there was very little evidence of autonomy and choice being promoted at the home. Some of the residents have complex mental health care needs and these are not being taken into account when planning activities. There was evidence of some activities taking place but these were inappropriate to the needs and abilities of the individuals. The providers will need to address this with urgency, as this has been a previous requirement. The providers will also need to show that individual residents are given choices in relation to the routines of the day and that personal preferences are upheld. This is in relation to all aspects of daily living including food preferences. The home must provide evidence that they are treating residents as individuals. To assist in achieving the above, the providers will need to ensure that all staff delivering care are equipped with the skills and knowledge of how to do this. The staff will need to be able to understand complex individual needs and how to offer support to these residents and their families. All care staff must have training in dementia care, mental illnesses and challenging behaviours. Comments received from relatives comment cards and from the GP comment card indicate that staff communication is a problem at the home. This was discussed with the managers at the time of the inspection. The providers will need to ensure that new staff have the necessary skills to be able to communicate with residents, families and other professionals. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 8 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.V292267.R01.S.doc Version 5.1 Page 9 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.V292267.R01.S.doc Version 5.1 Page 10 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 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are given the appropriate information in order to make an informed decision, however, it has been identified that the home is failing to meet some of these assessed individual needs. EVIDENCE: It was evident, through examination of care plans, that pre-admission assessments are taking place before individuals are offered a placement at the home. This is very often carried out by an assessing nurse from the home as well as from a Social Worker. The assessments were found to be thorough and informative and provided a base for which to develop a care plan. Residents and their representatives received a letter from the home confirming that the home was able to meet their assessed needs. Evidence obtained in other outcomes in this report identifies that not all individual assessed needs and specific complex social needs are being met. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 11 Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is making progress in this area with some encouraging evidence and positive feedback obtained. However comments from healthcare professionals are conflicting and would indicate that there is still some room for improvement and communication. EVIDENCE: Four care plans were examined from a random selection and case tracking of three individuals was carried out. One included the care plan of an individual admitted for respite, who had been encouraged to bring in her pet during the stay. The CSCI had received a copy of a letter sent from this lady’s Social Worker. This letter outlined how happy the Social Worker was with the care afforded to this individual during her short stay at the home especially in light of “adult protection issues” and went on to thank the staff for their “cooperation and sensitivity”. Plans were well constructed and reviewed on a regular basis. The personal needs of the residents had been identified. Discussions with one of the Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 13 gentleman who was case tracked confirmed that he felt that he received adequate help with meeting his personal care needs. Examination of his care plan confirmed that he also had his mental health nursing needs met including advice and treatment from healthcare professionals. Examination of another care plan in relation to case tracking identified that a lady had a number of physical nursing needs as well as mental health needs. These nursing needs were being met well with obvious involvement from professionals. The Palliative Care Nurse Specialist and the Tissue Viability Nurse Specialist were both involved in this lady’s care and their advice was being followed by the staff in the home. The staff were also managing this lady’s diabetes effectively. A relative was visiting this resident at the time and the inspector spoke with her at length. She confirmed that she was happy with the care afforded to her relative and took comfort from the fact that healthcare specialists were involved. In relation to case tracking, the care plan was examined of a lady who needed help with maintaining a comfortable and dignified sitting position whilst sitting in her chair. The chair was not appropriate for this lady and inspectors had identified this during the additional visit held in March. There was documentation to confirm that this lady had since been referred to the Occupational Therapist and was currently awaiting an assessment for another adapted chair. This lady also had problems with swallowing and, during the medication round, the nurse in charge used thickened fluids to assist her with taking her medication. It was refreshing to evidence the approach in which the senior person had completed the reviews of individual care plans, these being both detailed and informative. Staff were observed to be respectful and helpful to residents during the inspection. This was confirmed by a resident “the girls are good and help me”. The staff on duty were knowledgeable about the present resident group and their needs and addressed them in a sensitive manner. GP comments received indicated the following – The home does not always communicate clearly and work in partnership. There is not always a senior member of staff to confer with. The GP is not always able to see patients in private. Staff do not always demonstrate a clear understanding of the care needs of patients. Finally the GP comment card indicates that he/she is not satisfied with the overall care provided to patients within the home. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. The home is failing the residents in respect of meeting their individual social and therapeutic needs. Autonomy is not encouraged and there was little evidence of residents being able to exercise choice and control over their lives either directly or through their representative. EVIDENCE: There remained limited social interaction evidenced with the exception of a game of dominoes once a week for one person. The activities plan did not evidence the preferences, interests and hobbies of individuals. While the inspectors were informed that staff were involved with some social interaction there was no written evidence of this. There remains limited social and therapeutic activities for the people in the Beeches. Some evidence of residents’ gardening skills were displayed in the potted bulbs. Records evidenced identified that this section required more development for residents. The inspector spoke with the social activity person. She had prepared a programme for the Beeches that would be more proactive to meet the needs of the residents. Staff on duty told the inspector that they did try to explore activities with the residents. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 15 The meal of the day was Steak & Kidney pie or Beef Stew, there was no alternative to beef served. The cook told the inspector later that The Beeches had not asked for any other alternative. The pudding was a baked apple and custard; for the majority of the residents this was inappropriate. Residents were observed to leave the pudding because they could not manage the fruit in the format it was served. Two residents told the inspector that they did not eat the apple. This was relayed to the cook later. The gentlemen who was case tracked by the inspector stated that he was served food which he did not like and that no one had sat down with him to identify his likes and dislikes. Staff were observed helping the lady who had swallowing difficulties to eat and drink using thickened fluids. Case tracking also identified that the lady with complex nursing needs was being assisted to eat by her relative. The overall presentation of the lunchtime meal had improved since the last inspection. The menu had been changed over the weekend when the agency cook catered. This person had failed to record the fridge and freezer temperatures. The assistant cook did not have his Food & Hygiene qualification; he had watched the home’s in house video. This was discussed with the registered care manager at feedback. A recent visit from the Environmental Health Officer identified no major problems they did recommend redecoration as and when necessary. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 16 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 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are taken seriously by the General Manager and acted upon. Residents are protected from harm and abuse by the systems in place. EVIDENCE: The Commission had not received any formal or informal complaint since the last inspection. The home had the appropriate procedures and policies with staff awareness in place. Staff on duty confirmed that they were aware of the procedures to follow in the event of a complaint or any form of abuse being observed. The GP comment card indicated that he/she had received complaints about the home in the past. Staff on duty were spoken to by the inspector and confirmed that they had been provided with training for challenging behaviours, dementia and the care of Vulnerable Adults via an in house video and during the induction programme. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This home does not meet many of the minimum standards in respect of the environment. Externally the changes have been more encouraging and, once completed, will help to improve the outdoor space and facilities for the residents accommodated at the home. EVIDENCE: The presentation of the environment within The Beeches remained of concern. The providers had purchased new armchairs for Beeches 2 and these were in use at the time of the inspection. Beeches 1 was not inspected on this visit due to work taking place to remove asbestos from the unit. Beeches 2 remained unchanged in its decoration and with the exception of the chairs poor in its provisions of homely style furnishings and fittings. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 18 The hygiene standards were slightly improved with the kitchenette being maintained in a satisfactory manner at the time of the inspection. The concerns over bedroom 2 remained. There had been no change to the carpet, which was extremely malodorous. The resident informed the inspectors that he was to have a new wooden floor but he did not know when. The inspectors were told later at feedback that the floor had been measured for fitting within the near future. Following a comment from the gentlemen being case tracked regarding the lack of hot water in his bedroom this was checked and found to be accurate. This was made a short-term requirement to rectify the problem and fed back to the registered care manager. When asked why he was sitting in the entrance area to the home this gentleman replied, “I sit here because you don’t know what you’re sitting on in there. The chairs are often wet and I don’t want to keep changing my trousers”. This comment was raised to the managers during feedback. Auditing of this area of housekeeping has been recommended under standard 33. A letter had been received on 12/04/06 from the Facilities Manager with the following information:Purchase orders have been issues have been issued for: Remedial repairs and chlorination to the water systems in Beeches 1 and 2. Removal of asbestos in The Beeches. Replacement floor covering to The Beeches dining room, lounge and en-suite to room 19. On the day of the inspection work was taking place on the construction of the enclosed garden area for Beeches 1. A door leading off the lounge and into the garden had been constructed and a ramp was in the process of being built. The residents accommodated on this unit will then be able to benefit from a safe, accessible garden area. The enclosed garden area on Beeches 2 was in need of a tidy up and grass cutting before this could be deemed as safe. This should be done sooner rather than later so that residents accommodated on this unit can enjoy the summer months. The entrance to Beeches 1 and 2 are now both accessible to wheelchair users. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 19 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 is adequate. This judgement has been made using available evidence including a visit to this service. There are some very dedicated staff working at the home who have the required skills and experience but further staff training is required in order to ensure that the specific needs of the residents in this home are met on a continuous basis. EVIDENCE: The majority of the staff had recently completed Infection Control training and records were seen to confirm this. Some care staff have received dementia care training and commented that this had been beneficial and helped them to understand the specific needs of the residents in the home. This training now needs to be expanded to include all the care staff employed at this home. It was concerning to note that only two staff members are working toward NVQ level 2 in care with one more to be signed up. It is recommended that this too is expanded and that the home works toward ensuring that at least 50 of care staff are trained to NVQ level 2 or above in care. The recruitment procedure was examined and two employee files were seen. One contained no passport or birth certificate. The other file examined was found to contain the required information. Staffing was found to be adequate on this unannounced inspection. However, comments received from the relatives/visitors comment card read “staff cover Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 20 over weekends always seems at bare minimum – carers are also expected to do kitchen duties if there are no available kitchen staff”. The manager confirmed to inspectors that the problems encountered with kitchen staff shortages had now been sorted and that this was no longer a problem. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 21 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, 33, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The general management of the home had improved somewhat since the last inspection but the Manager is not yet registered with the CSCI. EVIDENCE: The CSCI had not received an application for Registered Manager for this home despite this being a previous requirement. This was discussed with the General and Regional Managers at the time and a timescale was agreed for this application to be received. There was an acting manager in post who had worked at the home over the past months and who would be applying for the post. It was evident, throughout the inspection, that this individual had had a positive impact on the home and that management of the units had improved Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 22 somewhat. There was also support in place from the General Manager (Registered for Standon Main Hall). The CSCI receives Regulation 26 reports from the Regional Manager on a monthly basis. Other audits had also been completed at the home, mainly in relation to care facilities. It is recommended that auditing moves on to include environmental issues, housekeeping, food and menus and social and therapeutic activities. All quality assurance surveys carried out should include the views of the residents and/or their representatives. Formal staff supervision had been commenced. Staff spoken to confirmed this and records were examined. A maintenance person who works full time at the home oversees the maintenance of the environment. He keeps records of the servicing and testing of equipment and these were seen at the time. The inspectors had some concerns over the fire escape doors in The Beeches and have requested a visit from the Fire Safety Officer in relation to this. Staff confirmed that they were receiving updates in mandatory health and safety training such as moving and handling and fire safety. Records were examined to confirm this. However, these records identified that some staff had not received any fire safety training and not all staff were attending the required number of fire drills. This was discussed with the manager at the time and will need to be addressed within the agreed timescale. Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 23 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 3 x x 3 x 2 Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 24 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 OP25 Regulation 23(2)(j) Requirement Timescale for action 04/05/06 2 3 OP26 OP38 4 5 6 OP32 OP29 OP30 7 8 OP12 OP14 That hot water be made available in the bedroom identified to the manager and that an audit is carried out to ensure that all bedrooms have an adequate supply of hot water. 16 (2)(k) That the flooring in bedroom 2 on Beeches 2 is replaced due to the mal odour. 23(4)(d,e) That all staff receive training in fire safety and attend the required number of fire drills and that this is recorded. 8 and 9 That the CSCI receives an application in respect of Registered Manager. 19 That proof of staff identity is schedule obtained and kept in the home 2 18(1)(a) That all care staff receive training in order to meet the complex mental health needs of the residents in the home. 16(2)(m,n That the social and therapeutic ) care needs of the residents are met on a continuous basis. 12(2) That autonomy and choice is upheld for the residents in the home and that this is DS0000022377.V292267.R01.S.doc 16/05/06 09/05/06 02/06/06 02/06/06 02/08/06 02/06/06 02/06/06 Standon Hall Care Home (The Beeches) Version 5.1 Page 25 9 10 OP19 OP8 23(2)(o) 12(1)(a) 11 12 OP10 OP27 12(4)(a) 18 (1)(a) demonstrated. That the garden area off Beeches 2 is made tidy so that this is safe for residents to use. The staff must work alongside the GP and in accordance with his directions, to ensure the healthcare needs of individuals are promoted. Staff must ensure that the GP is able to visit residents in the privacy of their own bedrooms. The providers will need to ensure that staff have the necessary skills to be able to communicate with residents, families and other professionals. 20/05/06 20/05/06 20/05/06 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 Refer to Standard OP33 Good Practice Recommendations That Quality Assurance is concentrated on Environment, housekeeping, food, menus and social and therapeutic activities and includes seeking the views of the residents and/or their representatives. It is recommended that the home works toward ensuring that at least 50 of care staff are trained to NVQ level 2 or above in care. 2 OP28 Standon Hall Care Home (The Beeches) DS0000022377.V292267.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. Extracts may not be used or reproduced without the express permission of CSCI Standon Hall Care Home (The Beeches) DS0000022377.V292267.R01.S.doc Version 5.1 Page 27 - 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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