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Inspection on 02/11/06 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 2nd November 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.

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

The home provides a tranquil rural setting for residents and has spacious grounds and views over the surrounding countryside for individuals to enjoy.

What has improved since the last inspection?

The consistency and general standard of care planning has improved since the last inspection. The meeting of individual healthcare needs has also improved over the last twelve months. The CSCI have received application for Registered Manager and the consistency of management at this home should contribute toward raising and maintaining standards.

What the care home could do better:

Specific needs relating to residents with confusion, dementia and other enduring mental health problems are not fully met. There was a need for improvement in relation to interaction with residents. There was no interaction shown at all from one member of staff in respect of the residents whom she was supervising. The home must ensure that all staff are equipped with the necessary skills and experience in order to recognise and meet the needs of residents at the home. This registered provider must produce an improvement plan in order to highlight how these needs will be met. Although some welcome changes have been made to the presentation of the environment over the last twelve months, the very nature and design of the buildings remain somewhat institutionalised and do not fully meet with current standards relating to this outcome. Neither does the home provide a suitably adapted environment for residents with confusion, dementia and other enduring mental health needs to live. The registered provider has been made aware of the need to improve the environment by previous inspection reports and meetings with the CSCI. An improvement plan is required in relation to this. The quality and quantity of some of the food served needs improving and there must be evidence to show that individuals are given choices in relation to meals.Individual preferences need to be documented in respect of the activities of daily life, and the providers must consider how they will ensure that residents with enduring mental health needs are given choices. Autonomy needs to be promoted at this home. The registered provider will need to ensure that individual spiritual needs are documented and met. Care plans must be completed in full and representatives of residents must be given the opportunity to attend reviews. The registered provider will need to improve the services delivered to residents as highlighted above.

CARE HOMES FOR OLDER PEOPLE Standon Hall Care Home (The Beeches) Nr Eccleshall Stafford Staffordshire ST21 6RN Lead Inspector Mrs Yvonne Allen 2nd Inspector Mrs Wendy Grainger Key Unannounced Inspection 2 November 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.V318400.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 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.V318400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. DE over 60 years only Date of last inspection Random Inspection done on 14/09/06 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. The home 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 and 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 and have the provision of a sink. Bathing and toilet facilities are located close 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. The fees charged by the home range from £334.20 to £555.00 per resident per week. This includes the free nursing care element and the range includes both funded and privately paying residents. Extra charges are made for hairdressing and toiletries. This information was provided by the home on 13/11/06. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of two key inspections for this home within the year. The inspection started on 02/11/06 and continued with a visit on 6/11/06 and 8/11/06. The whole process of the field visits took a total of 12 hours, as two inspectors undertook the main visit of 4.5 hours each on 02/11/06, then one inspector returned for 30 minutes on 06/11/06 and again for 30 minutes on 08/11/06. The reasons for this are explained within the context of the report. This home has received Random Inspection visits in between the two Key inspection visits within the year and there has been a meeting held between the CSCI and the providers to discuss proposals for improvement. Key standards were assessed using the following methods of gathering evidence – Direct observation Examination of records Tour of the home Discussions with staff members Discussions with managers Verbal feedback was given to the following company representatives at the end of the first field visit – The General Manager The existing Regional Manager (who is soon to leave this position) The new Regional Manager (who will be taking over this position) There were no comment cards distributed prior to this inspection and no Pre Inspection Questionnaire requested. These had been received at the previous Key inspection held earlier on in the year. There were no visitors present during the inspection visit and, due to the limited abilities of the residents; it was difficult to obtain their views and comments about the home. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Specific needs relating to residents with confusion, dementia and other enduring mental health problems are not fully met. There was a need for improvement in relation to interaction with residents. There was no interaction shown at all from one member of staff in respect of the residents whom she was supervising. The home must ensure that all staff are equipped with the necessary skills and experience in order to recognise and meet the needs of residents at the home. This registered provider must produce an improvement plan in order to highlight how these needs will be met. Although some welcome changes have been made to the presentation of the environment over the last twelve months, the very nature and design of the buildings remain somewhat institutionalised and do not fully meet with current standards relating to this outcome. Neither does the home provide a suitably adapted environment for residents with confusion, dementia and other enduring mental health needs to live. The registered provider has been made aware of the need to improve the environment by previous inspection reports and meetings with the CSCI. An improvement plan is required in relation to this. The quality and quantity of some of the food served needs improving and there must be evidence to show that individuals are given choices in relation to meals. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 7 Individual preferences need to be documented in respect of the activities of daily life, and the providers must consider how they will ensure that residents with enduring mental health needs are given choices. Autonomy needs to be promoted at this home. The registered provider will need to ensure that individual spiritual needs are documented and met. Care plans must be completed in full and representatives of residents must be given the opportunity to attend reviews. The registered provider will need to improve the services delivered to residents as highlighted above. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 8 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.V318400.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents undergo a full assessment of needs prior to admission to the home but some improvements are needed to ensure that all individual assessed needs are fully met. EVIDENCE: Examination of a sample of care plans identified that pre admission assessments are undertaken by the acting manager prior to admission of residents to the home. Discussions with the acting manager confirmed that she only accepts emergency admissions to the home after having received the full assessment of individual needs from the funding body – usually a Social Worker. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 10 Assessments which had been carried out by funding bodies such as Social Services were seen contained within care plans. As highlighted in other outcomes throughout this report, not all individual assessed needs are met fully by the staff at the home and there is a need for improvement. This home does not accept residents for intermediate care. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual health care needs are assessed and monitored at the home. Personal care is planned and documented but care plan records are not always fully completed. More involvement by individual representatives would enhance the care delivered and help to measure whether individual needs are being met by the home. EVIDENCE: Examination of care plans identified that risk assessments had been carried out including those relating to challenging behaviour and falls. Care plans had been developed for these, both long and short term. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 12 Reviews of care plans had taken place but often not with the involvement of the individual resident and/or their representative. The recording of the individual biography was incomplete for a resident who had been admitted on Beeches 2 in August of this year. The inspector was informed that this resident’s family regularly visit. However, the social history had not been obtained or completed by the staff at the home. The inspector was unable to evidence, therefore, whether this gentleman’s social, therapeutic and/or spiritual needs were being met at the home. There was evidence, throughout the care plans, of referrals to and visits by the General Practitioner. The inspectors were informed that there was a very limited NHS Chiropody service in the local area and that this service was only available to those individuals with certain underlying medical conditions. The general manager explained that some of the care staff have undergone training in the foot care course and are able to cut nails as part of the personal care delivered. The registered provider will need to ensure that this training is recognised and certificated. The process for medication administration was found to be in keeping with requirements. The acting manager explained the systems in place for the ordering, storage recording and administration of medication and examination of record charts confirmed that this system was safe and run in the best interests of individual residents. It was difficult to ascertain whether residents felt that they were treated with dignity and respect. Most of the residents were unable to communicate fully with inspectors due to their limited mental capacities and there were no visitors present at the time of the visit. Staff were observed to be respectful toward residents whilst carrying out personal care and serving meals. Personal care was undertaken either in the individual’s own bedroom or the bathrooms/toilets. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had improved in its ability to meet the social and therapeutic needs of the residents accommodated there. However it is still failing to promote autonomy and individual choice in other areas of daily life. EVIDENCE: Evidence gained from the records maintained by the activity co-ordinator identified that there had been an improved input into activities for the residents in this home. A discussion with her at the time of the visit confirmed the above. The inspector had concerns as to the training and experience of one member of the staff who failed to interact with residents in Beeches 2. The member of staff showed no interaction with any of the residents and was for most of the time, standing at the back of chairs observing the room. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 14 The area manager who was visiting at the time of the inspection also observed this. No visitors came to either unit during the inspection visit. The meal of the day was recorded as meat & potato pie or cheese and onion pie followed by baked egg custard. The main part of the lunch appeared satisfactory. No resident on either of the two units received the alternative to the menu. The cook told the inspector that he had not received any indication what Beeches 1 required from the prepared lists, and as a result, he had served all meat and potato pie. The sweet/pudding was a plain plum tart with custard. The pastry had shrunk into the flan tin, was burnt around the edges and the plums were sparse on the pastry. The tin was served for ten residents on Beeches 1and was inadequate to offer a substantial portion. This was discussed with the cook; the inspector was told that Beeches 1 always had that size flan tin for pudding. The home had, according to the cook, eight eggs left and therefore was unable to prepare the baked egg custard. Fresh produce including eggs were delivered three times a week. There appeared to be poor planning from the cook as the menus were written for a month’s period and sufficient stock should have been made available. The inspector had concerns as to how the residents at this home chose from the daily menus, no suitable system was used in order to help residents with limited mental capacities. This was discussed with the acting manager and other managers at the time of the inspection. A suitable system must be developed in order to enable individual choice. There was very little evidence of the promotion of autonomy and choice for individuals accommodated in this home. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Representatives of residents accommodated in the home have access to the complaints procedure, but communication is not always adequate and the provider will need to ensure that all staff have a basic understanding and good communication skills. EVIDENCE: There was a clear and accessible complaints procedure displayed within the home. The acting manager explained that she deals with any concerns and talks to families about these. The General Manager deals with complaints, sometimes in conjunction with the Regional Manager. Records are maintained of these including any action taken. The CSCI had received and investigated one complaint in relation to the home since the last inspection. The areas of concern raised were in relation to poor personal care and a lack of communication from staff. Some aspects of this Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 16 complaint were upheld by the CSCI and subsequent requirements were made at the time. Staff are carefully selected to work in the care home and undergo police criminal checks before they are offered a position at the home. Staff also receive training in Protection of Vulnerable Adults and local procedures. It was identified, through conversations with two staff members on duty, that they had a limited understanding of spoken English and a limited knowledge of the needs of individuals. With this in mind, the manager will need to ensure that their comprehension of the vulnerable adults procedures is not compromised. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The presentation of this home does not meet the specific needs of the residents for which the home is registered and offers very little in the way of home comforts. EVIDENCE: Requirements made on the previous inspection visit had been partially addressed. The requirement to make good the flooring in the large lounge on Beeches 2 had not been addressed and remained a hazard. The timescale for this was 14 10 06. The inspectors were shown an order to replace the flooring dated 19 10 06 five days after the cut off timescale period. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 18 Beeches 2 ambient air temperature was below the required 70 degrees Fahrenheit. The heating in Beeches 1 was satisfactory. It appears that there was a problem with the heating and inspectors were informed that a part for the boiler in Beeches 2 had been ordered. No alternative provision had been made until this was pointed out whence portable oil filled heaters were provided. The safety of the resident in bedroom 19 was a potential hazard with a carpet that was uneven and required attention. A number of the metal commodes in Beeches 2 were in an unacceptable condition the plastic covering was breaking up and exposing bare metal. This is a potential area to breed germs and a possible hazard to delicate skins. The reclining chair, in which a resident was seated in the lounge area, was in a poor hygienic condition and required attention. The condition of some of the beds made for the residents to return to later were unacceptable with the bottom sheet being badly creased, one resident had a turquoise towel to lay on, on top of her sheet. The conditions of the beds and the towel were pointed out to the care manager during the inspection of the units. No bedroom had a lockable facility. Standard 24.7 clearly indicates a lockable storage space should be provided. At this time the residents in the Beeches do not have an option. The sluice in Beeches 2 was found to be unlocked despite the notice on the door. This is a potential hazard and should remain locked when not in use. The ambient air temperature in the bathroom in Beeches 2 was found to be at a temperature of 58 degrees Fahrenheit. The radiator was not working and the water registered 35 degrees centigrade. There was evidence left in the bath (bubbles) and confirmation by the staff that one resident had been bathed this morning. This action was unacceptable and poses a health risk to residents bathed under these conditions. The water pressure in the bathroom in Beeches 1 was exceptionally poor. Moreover this bathroom did not have any means of testing the water prior to a resident being bathed. Thermometers should be made available in each of the bathing facilities to protect residents used. Two of the bedrooms visited had a malodour. A number of the bedrooms had a non slip vinyl flooring perhaps this flooring should be considered if the system used to clean carpets is not effective to prevent odours. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 19 Some rooms had personal possessions displayed, pictures in some rooms were very pleasant. Other rooms as would be expected were plain and little possessions displayed. In Bedroom 6 a fire door had been negated where the lock was removed leaving a hole in the door. There is a requirement to take precautions against the risk of fire. The ramp at the front of Beeches 1 had been identified as a risk area following any inclement weather. Grit has to be put on to maintain a slip free ramp. This is a hazard as residents use this area as observed during the inspection. There has been very little adaptation made to this environment in relation to meeting the needs of residents with varying degrees of mental health including those who suffer from confusion and dementia. There were very few examples of pictorial signs to help with orientation and the environment lack visual and sensory stimulation. The lack of central heating throughout Beeches 2 unit gave rise for concern regarding the wellbeing of residents accommodated at this home. An immediate requirement was left for the providers to address this. A further visit made to the home on 06/11/06 identified that, although the central heating was still not working, contingency plans had been put into place to ensure that the residents were kept warm. A telephone call was received on 07/11/06 from the General Manager to confirm that the central heating system was now back in working order. A visit was made to the home on 08/11/06 when it was identified that the central heating in the home was working adequately. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staffing numbers and skills are adequate but there is still a need for improvement with further staff training and communication skills in order to ensure that all individual specific needs are recognised and met. EVIDENCE: The numbers of staff on duty at the time of the inspection was in keeping with the existing staffing notice. The acting manager was the nurse on duty and was assisted by two care staff on Beeches 2 – for a total of 15 residents with nursing needs and there were 2 care staff present on Beeches 1 – for a total of 10 residents with personal care needs. On night duty there was 1 qualified nurse on duty and 2 care assistants (one each unit). Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 21 Ancillary staff worked between this home and the other home on the complex and included a housekeeper, domestic and laundry staff, a cook and kitchen assistants. There was also a full time maintenance person employed by the home who was responsible for both homes. The members of staff spoken to included the acting manager, the general manager, two care assistants, the cook and the housekeeper. The care staff and the acting manager commented that they felt well supported at the home with their training needs. As required at the last inspection, staff training in dementia care and other mental health related training has been organised for December as not all staff had received this. Some of the residents accommodated on this unit have very challenging mental health needs and staff require specific training in this area in order to be able to meet these individual needs. The staff spoken to stated that they had received update training in moving and handling and fire safety. There was evidence of this and other mandatory training having been undertaken in staff training files. Observation of a care assistant on duty on Beeches 2 at the time of the visit indicated that there was a need for more basic training. She was supervising the lounge at the time and there was little or no interaction noted between this care assistant and the residents under her care. The male care assistant on duty on Beeches 1 had very limited command of the English language and was difficult for the inspectors to understand. This was of concern, as it would follow that the residents would have even more difficulty understanding this carer. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Continuity of the management of this home will help to raise standards but financial input by the providers is required in order to support and achieve this. EVIDENCE: The CSCI had recently received an application in support of Registered Manager for this home in accordance with the requirement of the previous inspection report. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 23 The acting manager was on duty at the time of the inspection and discussions were held with her regarding different aspects of the management of the home. The General Manager, who is also the Registered manager for Standon main hall, provides support at The Beeches wherever required. It was identified that management plans for the development of this home will need financial support from the providers. This was discussed during feedback to the Regional Manager and General Manager at the end of the inspection. The administration of residents’ finances was assessed and records relating to these were examined during the inspection visit. These were found to be in keeping with requirements at the time. The fire records for the prevention and testing of the fire system were observed and found to be satisfactory on this inspection. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x 2 1 x 2 1 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x 2 Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 25 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 OP15 Regulation 16(2)(i) Requirement The registered person shall provide, in adequate quantities, suitable wholesome and nutritious food, which is varied and well prepared. This refers to the serving of puddings The registered person must ensure that all parts of the home including the external environment to which residents have access, is free from possible hazards. This refers to ensuring that the external ramp outside Beeches 1 front entrance is non-slip. The registered person must take precautions in the event of a fire and ensure that residents are safe in their environment. This refers to repair or replacement of the bedroom door identified. The registered person must ensure that all nursing staff undergo training in dementia awareness and managing challenging behaviour and possess the necessary communication skills. The registered person must DS0000022377.V318400.R01.S.doc Timescale for action 20/11/06 2. OP38 13(4)(a) 20/11/06 3. OP38 23(4)(c) 20/11/06 4. OP30 18 (1)(a) 14/12/06 5. OP21 23(2)(j) 20/11/06 Page 26 Standon Hall Care Home (The Beeches) Version 5.2 6. OP19 23 (2)(b) 7 OP25 23(2)(p) 8 OP22 16(2)(c) 9 OP38 13(4) 10 11 OP24 OP38 12(4)(a) 13(4)(c) 12 OP7 15(2)(c) 13 OP7 16(2)(m) ensure that baths are fitted with a hot and cold water supply and adequate water pressure, and a temperature appropriate at all times. The registered person must ensure that the flooring in the lounge in Beeches 2 is made good. PREVIOUS TIMESCALE of 14/10/06 NOT MET The registered person must ensure that the heating throughout the home is suitable for the residents at all times and in the event of a failure provide appropriate alternative heating. The registered person must replace the commodes identified to be in poor hygienic and physical condition. The registered person must restretch or replace the carpet identified in the report to prevent a potential hazard. The registered person must provide a lockable facility in all the rooms occupied by residents. The registered person must ensure that unnecessary risks to the health and safety of the residents are eliminated by maintaining a locked door to the sluice when not in use. The registered person must ensure that individual residents and/or their representatives are given the opportunity, wherever possible, to participate in the review of care plans The registered person must ensure that records relating to care plans are completed. This relates to social histories/spiritual wishes. 14/11/06 20/11/06 30/12/06 20/11/06 20/02/07 20/11/06 20/11/06 20/11/06 Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 27 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 OP25 Good Practice Recommendations To provide working thermometers in all the bathrooms for the staff to use for any full body emersion. Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Standon Hall Care Home (The Beeches) DS0000022377.V318400.R01.S.doc Version 5.2 Page 29 - 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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