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Inspection on 21/06/05 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 21st June 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

The home is able to offer specialist care for residents with severe mental health care needs. There are many loyal and dedicated staff employed at the home who are very caring and compassionate.

What has improved since the last inspection?

Since the last inspection the cleanliness of the environment has improved, as has the provision of adequate bedding. New mattresses and easy chairs have been provided. Some bedrooms have had new furniture and new flooring fitted and a new entrance/reception area has been built to Beeches 2. Staff have received updates in mandatory health and safety training and records have improved. A prospective manager has been employed with a view to being registered. The manager has the required skills and expertise to run the home and is both enthusiastic and dedicated to ensuring the well being of the residents accommodated there.

CARE HOMES FOR OLDER PEOPLE Standon Hall Care Home (The Beeches) Near Eccleshall Stafford Staffordshire ST21 6RN Lead Inspector Yvonne Allen Unannounced 21 June 2005 10:00 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 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) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Standon Hall Care Home (The Beeches) Address Near Eccleshall Stafford Staffordshire ST21 6RN 01782 791555 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Standon Hall Home Ltd Care Home 34 Category(ies) of 34 DE registration, with number 34 DE(E) of places Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: DE over 60 years only Date of last inspection 05 January 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) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection from 10am through to 5pm. The inspection consisted of a tour of the home where a selection of bedrooms and all communal areas were inspected. Inspectors spoke with some of the residents, various members of staff and a visiting relative. Relevant records and documentation were examined and discussions were held with the prospective general manager of the home. At the end of the inspection feedback was given to the manager. This home is in great need of financial input from the providers and the home would be better rebuilt to current building standards. The home is not conducive to “homely” living and does not lend itself to achieving the standards expected and deserved by residents and staff in 2005. Between the last inspection in January and this inspection, there had been four monitoring visits made to the home plus a meeting with the providers. After the inspection in January admissions to the home were temporarily put on hold until requirements were addressed and improvements made. After the following monitoring visit the home started to take admissions again. At each monitoring visit the home was inspected to see if requirements were being addressed within timescales. The inspector was satisfied that the company were addressing issues of concern and slowly making some improvements to the home. There are however 26 Statuatory requirements needing action. These must be completed within the given timescale or the CSCI will be mindful to later enforcement action against the company. What the service does well: What has improved since the last inspection? Since the last inspection the cleanliness of the environment has improved, as has the provision of adequate bedding. New mattresses and easy chairs have been provided. Some bedrooms have had new furniture and new flooring fitted and a new entrance/reception area has been built to Beeches 2. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 6 Staff have received updates in mandatory health and safety training and records have improved. A prospective manager has been employed with a view to being registered. The manager has the required skills and expertise to run the home and is both enthusiastic and dedicated to ensuring the well being of the residents accommodated there. What they could do better: Care plans require attention and need to reflect the actual care both delivered and received. The standard of care panning need to be made consistent. The assessment, provision and monitoring of individual healthcare needs requires urgent attention and improvement. The number of hours dedicated to therapeutic activities needs to be increased as outlined and activities need to be geared to meeting individual preferences and abilities. Menus need to include the provision of fresh seasonal fruit on a regular basis. A safe, well-maintained enclosed garden must be provided in Beeches 1 and the area provided for this purpose in Beeches 2 must include garden furniture to sit on so that residents can enjoy the warm weather. For residents accommodated in Beeches 1, a ramp must be provided over the front entrance so that wheelchair users can also enjoy this facility. The exterior of the home must be maintained in a good decorative order, as must the gardens and pathway leading up to the new entrance to Beeches 2. Locks must be provided on toilet doors so that privacy and dignity are maintained. The programme of redecoration and refurbishment must continue to ensure that all areas of the home are well maintained. This must include new flooring in bedrooms identified. The environment must have an occupational therapists’ assessment to ensure that it is conducive to meeting the needs of individuals. Adequate staffing levels must be maintained and monitored at all times. The company will need to ensure that the manager is supported in her position so that management is secured and remains consistent. Staff at the home have been through many changes and are in of need stability and support. Formal staff supervision will need to be developed and records maintained. Staff also require further training in dementia care and mental health needs to ensure that all staff delivering care are able to fully understand and meet the needs of individual residents. New staff must receive thorough induction training and the home will need to maintain evidence of this. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 7 The views of residents and/or representatives must be sought in relation to the maintenance of care plans and the services delivered by the home. Their views and suggestions must be acted upon and there must be documentary evidence of this. Health and safety issues must be addressed in relation to the practice of propping open bedroom doors and the documentation of the testing of emergency lighting. As a matter of urgency, the work required on the water tanks must be addressed in order to ensure public hygiene and safety. 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) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Residents entering the home receive a full assessment of needs undertaken by suitably qualified professionals. Individual needs are not always met fully, consistently and effectively. EVIDENCE: All residents are assessed before being offered a placement at the home. There was evidence of these pre-admission assessments contained within care plans. The inspector examined two care plans relating to residents who had been admitted to the home since the last inspection. Both of these residents had undergone a comprehensive assessment of their needs prior to being admitted to the home. The prospective manager had undertaken this. Assessments had also been carried out by social services who were involved in the admission process. Prior to this, the psycho-geriatrician had also carried out his own assessment of mental capacity/needs. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 10 It is the home’s policy to confirm, in writing; to the representatives that the home can meet the resident’s assessed needs. This is in accordance with the regulations (regulation 14). This practice will need to continue. Care Plans identified that individual assessed needs were not always met in a consistent manner as outlined under standard 7. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care planning system lacks consistency and care plans do not always reflect the care required and/or delivered. The meeting of healthcare needs is haphazard and inconsistent. Residents were treated with dignity and respect and medication procedures were satisfactory. EVIDENCE: A selection of care plans was examined from both units. The prospective manager stated that she was in the process of carrying out an audit of the care plans in the home. In one of the plans relating to a resident recently admitted to the home, there was a “do not resuscitation policy”. This had been included at the request of the family who had Power Of Attorney. This was discussed with the manager as needing further clarification. It is important that the manager obtains a copy of the Power Of Attorney – which needs to be Enduring. She was also advised to include the opinion of the GP and social worker (if any) and to seek advice from a legal representative so that the right of the resident is upheld. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 12 The care plan was detailed and risk assessments had been developed but it was not yet completed. This resident had been admitted to the home on 7/6/05. There was concern that this gentleman had not yet been weighed nor had an oral assessment, although a risk assessment suggested that he needed a care plan in relation to nutrition. Another resident who had been admitted very recently had not been weighed although the care plan suggested that monthly weight checks were needed. There had been a requirement left after the last inspection in relation to monitoring weights of residents. Improvement is required in this area. The care plan of a resident who had been in the home for two years was examined. This was found to be a month behind with evaluations. There was no evidence of the named nurse on this plan. There was some evidence of referrals to the GP when required. In another care plan the intention to refer to a Physiotherapist was observed, and whilst from discussion with staff it was known that this had happened, and a visit had been made, there was no record of either the visit, or of the advice regarding ongoing treatment arising from this visit. In the same care plan there was some confusion over the wording relating to clothing, and to the fact that the care plan appeared to contradict the expressed wishes of the resident, though inspectors were assured that this was not the case, but was due to English not being the first Language of the writer. The plans contained very little evidence of visits by the chiropodist or other healthcare professionals. There had been a requirement following the last inspection in relation to this. This needs to be improved. There was also little evidence of consultation with families/representatives. The nurse was observed administering medication to the residents. Policies and procedures were being followed as required. Documentation relating to the storage and administration of medication was examined and found to be in order. The nurse’s knowledge of the policies and procedures relating to medication was good when questioned. Staff were seen to be attentive to the needs of the residents. It can be challenging to maintain privacy and dignity for some of the residents with severe mental healthcare needs. Staff spoken to were aware of the importance of this. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Residents did not receive adequate therapeutic stimulation. This requires addressing and further development in relation to the quantity and quality of activities provided, availability of outdoor facilities and the review of menus. EVIDENCE: There was one activity co-ordinator working 25 hours per week and covering both homes. Throughout the course of the inspection there was evidence that this was inefficient. The co-ordinator was very dedicated and tried very hard to offer her services to both homes. Inspectors noted that she was only in attendance on one afternoon per week on Beeches 1 and the same for Beeches 2. Occasionally this would be twice per week. During the morning residents appeared bored and lacked stimulation. It is also required that another activity co-ordinator is employed so that the provision of dedicated activity hours is raised to a minimum of 50 hours per week between both homes. It is also required that the activity co-ordinator allocated to this home receives training in offering therapeutic activities to residents with these special needs. It has been a previous requirement that more activity hours are provided and this has not been addressed. It was a lovely day and the residents could not go out as, although the garden had been made safe on Beeches 2, there was no garden furniture and no where to sit. Beeches 1 were much the same with very limited access to Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 14 external space. There was no ramp to the door so anyone in a wheelchair could not access the patio area at the front. This patio to Beeches 1 was not secure as staff were constantly having to keep an eye on the residents out there to stop them wandering off. It is required that garden furniture is provided for Beeches 2 and that a safe and secure garden area is provided for Beeches 1 with a ramp leading off from the entrance to the home. Links with the community were limited due to the position of the home and the small size of the village nearby. There was an open visiting policy and visitors were welcome at any time. The lunchtime meal was observed. There was evidence of a choice available and two residents in Beeches 1 were having a salad instead of the main meal. This was seen to be beautifully presented and looked delicious. The residents were obviously enjoying this. Special diets are catered for and there were some residents receiving diabetic alternatives. It was observed that the menus contained very little fresh fruit dishes. It is a requirement that fresh fruit is introduced such as fresh fruit salad, and/or a fresh fruit platter served on some afternoons instead of biscuits. Also staff commented that residents never had any seasonal fruit such as strawberries. This fruit would offer variety and stimulation to residents, and would be extremely beneficial to those residents suffering from Dementia as it would expand the range of senses being stimulated, and might provoke pleasure cells in the brain that were still functioning in someone who otherwise had very few pleasurable experiences left. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and their representatives could be assured that their complaints and concerns would be listened to, taken seriously and acted upon. Residents were protected from harm by the systems in place at the home. EVIDENCE: There was a clear and accessible complaints procedure in place at the home. The CSCI had received one complaint since the last inspection, which had been investigated and partly upheld. The prospective manager was fully aware of how to address and record complaints. The regional manager would also assist in dealing with complaints. There was a local policy in place for the protection of vulnerable adults and staff had received training on the reporting of abuse. As part of the recruitment process staff undergo a Criminal Records check and their name is checked against the Protection Of Vulnerable Adults list. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of décor and furnishings in the environment had improved since the last inspection. Although this was pleasing there were some areas still in need of attention. EVIDENCE: The environment had improved since the last inspection. There were many requirements made in relation to the environment at the last inspection and monitoring visits had been made to ensure that these requirements were addressed. Many of the bedrooms had been redecorated and some had been refurbished. Corridor areas and communal bathrooms and toilets had been repainted and looked brighter, cleaner and more attractive. Some of the beds had been replaced, new mattresses had been purchased and new bedding had been provided. New easy chairs had been purchased for lounges; new coffee and occasional tables and a large modern television had been provided. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 17 The manager stated that the lounge area in Beeches 2 was to have new flooring and replacement of easy chairs. A new entrance area had been created for Beeches 2 and was almost complete. This now required new paving to the outside leading up to and in front of the new entrance. The current pathway was a health and safety hazard with many uneven and broken paving slabs. This must be attended to before visitors are allowed to use it. There were two bedrooms seen where doors were propped open with extraneous items. This practice contravenes fire safety requirements and must cease. Where residents prefer their bedroom doors propped open, this must be done using a door guard unit of the type approved by the fire safety officer. He should be consulted prior to duty. In bedroom 1 on Beeches1 new flooring is required. The exterior of the home is in great need of attention for both Beeches 1 and 2. Repainting is required for the whole of the exterior. The enclosed garden area at the rear of Beeches 2 was in need of attention as this was becoming unkempt. It is a requirement that a gardener is employed to maintain the garden and grounds to an acceptable standard. The rear of the home externally, overlooking the enclosed garden, was dirty and covered in cobwebs and in great need of a thorough clean. It was noted that there were no locks provided on toilet doors. In respect of maintaining privacy and dignity these must be provided and be of the type that can be overridden in case of emergencies. The toilet located in the toilet area off Beeches 2 lounge had a broken cistern lid and was leaking. This required immediate attention and was referred to the maintenance person by the manager. Although improvements had been made in relation to the environment, the programme of redecoration and refurbishment will need to continue so that all areas of the home have had attention. Some of the vanity units and furniture in bedrooms were broken and in need of replacement. An audit must be carried out and a replacement programme commenced. The environment will need to be adapted to offer more in the way of stimulation and orientation for residents with these special needs. It is a requirement that an assessment of the environment is conducted by an occupational therapist, the results of which are forwarded to the CSCI. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Some immediate adjustments were required in relation to the number of care staff provided in Beeches 1 and the number of activity hours provided for the home. Staff are carefully selected and vetted before being employed by the home. Mandatory staff training is on going with regular updates received. There will need to be evidence of staff induction records. EVIDENCE: The CSCI had recently received a review of staffing letter in relation to Beeches 1 and 2. On Beeches 1 there was a total of 9 residents, 8 were in receipt of personal care and 1 was receiving nursing care. The staffing had been reduced from 2 care assistants all day to 1 care assistant. Staff commented that they were concerned about the safety of this. They had concerns about the practicalities of being able to monitor wandering residents and give personal care and baths to other residents at the same time. The lunchtime period was observed with the care assistant trying to give out lunches and supervise residents in the dining room whilst at the same time monitoring a resident who wanted to go outside. There was also a resident dining in his bedroom who was in need of encouragement and assistance with his meal. The situation was unmanageable with one care assistant on duty. An immediate requirement was left that staffing on this unit reverts back to 2 care staff on daily from 8am-8pm. On Beeches 2 there was a total of 17 residents receiving nursing care. A number of which had very challenging mental health needs. The staffing levels on this unit had been reduced to 3 care staff from 8am-5pm then 2 from 5pm Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 19 –8pm. There is a trained nurse on duty throughout each 24-hour period. The staff spoken to on this unit felt that this was manageable with the number of residents accommodated. The nurse in charge was a Registered Mental Nurse and appeared competent and efficient. The staffing on this unit must be monitored and should the number of residents accommodated in Beeches 2 increase then staffing levels must be increased accordingly. The numbers of domestic, laundry and kitchen staff provided had not changed but appeared sufficient for the maintenance of the home. The maintenance person who had worked at the home for many years had recently retired and a replacement had been appointed. He will be working full time over two homes and will need to be supported by gardeners. There was an administrator appointed over both homes. As outlined under standard 12 activity hours provided will need to be increased to a minimum of 50 over both homes. Mandatory staff training was on going at the home with most of the staff having received update training in moving and handling, fire safety, fire drills, infection control, first aid, health and safety, POVA, food hygiene and customer care. There were now 5 moving and handling trainers employed between both homes. The training matrix was examined and staff were questioned about the training they had received. Some dementia care training had taken place but this needs to be expanded so that all nursing and care staff are aware of the needs of these residents and have the ability to be able to meet their needs efficiently. This was discussed at length with the manger and advice was offered in relation to training by the inspectors. New staff receive induction training to TOPPS standard but there was no documentary evidence in place to support this. There will need to be documentary evidence of induction programmes having been completed, with mentors working alongside new staff until the new staff member has been signed off as proficient in all the areas covered. Two employee files were reviewed for the most recently appointed members of staff, and the standard contract used by the company was felt to be comprehensive, with references to probationary periods of employment only being made permanent after satisfactory reviews, no person being able to work in the home without satisfactory C.R.B. checks being received, two written references being taken, [in practice these were said later by the acting manager to be her record of a telephone reference as people were either reluctant or tardy to reply to requests for references. Standard policy was then to send a copy of these transcripts to the referee, and obtain a signature.] Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 20 Contracts also referred to mandatory and specialist training required for the named job, to the requirements of Health and Safety, to the Data Protection Act, and to the importance of “Whistle Blowing” to uncover poor practice, and protect vulnerable adults from abuse and potential abuse. Applicants had also been asked to provide certificates and any other proofs of education, training, competence, and previous experience, and copies of these were seen on the files. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, 37 and 38 The home is in need of stability and consistency in relation to management and it is essential for the maintenance of this home that this is achieved without delay. There are some issues in relation to the health and safety of residents and staff which are in need of urgent attention. EVIDENCE: The prospective general manager over the home had applied for registration. This application was being processed by the CSCI. She works supernumery over both homes. Standards 31 and 32 were not met, as the manager was not yet registered with CSCI. The Deputy Manager for The Beeches had left some weeks prior to the inspection. She had not been in post for very long before resigning. She will need to be replaced without delay in order to regain stability over the units. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 22 The staff at the home were just starting to settle down again after having seen a lot of changes in management. The prospective manager had started some auditing of services. She had started with care plan audits and would be developing this into the other services offered by the home. Quality audits will need to include the views of the residents and/or their representatives and the results of surveys must be displayed in the home along with actions taken. A copy of these must be available for inspection. This has been a previous requirement but because of the lack of continuity in managers had not been addressed. The manager stated that there was a residents/relatives meeting planned for July. The CSCI had received a letter from the company accountants, following the last inspection, to state that the company was financially viable. The certificate of public liability insurance was on display in the home and was in date. Formal staff supervision had not commenced and will need developing. This was discussed with the manager at the time of the inspection who stated that she would be addressing this in the near future. Records were kept securely and in accordance with Data protection. Records and documentation relating to the maintenance of a safe environment were examined. Fire alarms had been tested and recorded weekly. The testing of emergency lighting was haphazard and documentation was recorded when lights were not working but there was nothing to state what had been done about this. It was very concerning to see that the work on the water tanks had not been addressed as required by the National Water Treatment Agency in relation to legionella testing. This requires addressing as a matter of urgency. PAT testing had been done in February 2005. A Gas safety certificate was in place but comments on this outlined that appliances were in “poor” condition. These will need to be monitored and replaced as necessary. The hoists had been examined and tested as required. Hot water temperatures had been tested and documented as required. Accidents and incidents had been recorded and reported as required. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 2 2 2 2 3 2 STAFFING Standard No Score 27 1 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 1 2 3 x 1 3 1 Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? 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 4, 7 and 8 Regulation 14 and 15 Requirement There must be evidence contained within care plans that individual personal and healthcare needs are met fully, effectively and consistently. Individual plans must be evaluated by the named nurse on a monthly basis or more often as required and provide evidence of consultation with the resident and/or the representative. Residents must be weighed on admission and as required in the care plan and this must be recorded. Care plans must contain records of visits from professionals including the advice and/or treatment recommended by them. There must be clear directions in relation to resucitation of individual residents and this must be agreed with the resident, and/or the representative, medical practitioner and members of the primary care team and documented in the care plan. The provision of therapeutic activities must be increased to Timescale for action Immediate and on going Immediate and on going 2. 7 15 3. 7 and 8 15 and 12 Immediate and on going Immediate and on going Immediate and on going 4. 7 and 8 15 and 12 5. 7 15 6. 12 16 By 25/7/05 Page 25 Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 7. 12 23(2)(o) 8. 15 16(2)(i) 9. 19 23(2)(b) 10. 19 23(4)(a) 11. 12. 13. 19 19 19 23(2)(b) 23(2)(b) 23(2)(b) 14. 15. 19 21 23(2)(b) 23(2)(e) 16. 24 16(2) 50 hours per week between both The beeches and Standon Hall Care Home and activity coordinators must have the necessary skills and expertise. It is required that garden furniture is provided for Beeches 2 and that a safe and secure garden area is provided for Beeches 1 with a ramp leading off from the entrance to the home. It is a requirement that fresh fruit is introduced such as fresh fruit salad, and/or a fresh fruit platter served on some afternoons instead of biscuits. The current pathway leading to the new entrance to Beeches 2 was a health and safety hazard with many uneven and broken paving slabs. This must be attended to before visitors are allowed to use it. Where residents prefer their bedroom doors propped open, this must be done using a door guard unit of the type approved by the fire safety officer. In bedroom 1 on Beeches1 new flooring is required Repainting is required for the whole of the exterior of Beeches 1 and 2 It is a requirement that a gardener is employed to maintain the garden and grounds to an acceptable standard. The rear of the home externally, overlooking the enclosed garden, must be thoroughly cleaned. Locks must be provided on toilet doors and be of the type that can be overridden in case of emergencies Some of the vanity units and furniture in bedrooms were broken and in need of By 25/8/05 Immediate and on going By 25/8/05 and before use Immediate and on going By 25/8/05 By 25/10/05 By 25/8/05 By 25/8/05 By 25/8/05 By 25/8/05 Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 26 17. 22 23(1) 18. 27 18(1) 19. 20. 27 30 18(2) 18(2) 21. 30 18(2) 22. 31 and 32 8 and 9 23. 33 24 24. 25. 36 38 18(2) 23(4)(b) replacement. An audit must be carried out and a replacement programme commenced It is a requirement that an assessment of the environment is conducted by an occupational therapist, the results of which are forwarded to the CSCI A minimum of two care staff must be provided from 8am-8pm on Beeches 1 and the staffing on Beeches 2 must be regualrly monitored and increased should occupancy increase. There must be a Unit Manager provided for The Beeches All Nursing and Care staff must receive training in dementia awareness and related mental health care needs. There will need to be documentary evidence of induction programmes having been completed, with mentors working alongside new staff until the new staff member has been signed off as proficient in all the areas covered. The prospective manager will need to be registered by the CSCI and stability and consistency of management is required at the home. Quality audits will need to include the views of the residents and/or their representatives and the results of surveys must be displayed in the home along with actions taken. A copy of these must be available for inspection. Formal staff supervision had not commenced and will need developing. Emergency lighting must be tested and recorded as required with documentation maintained of action taken with faults. By 25/8/05 Immediate and on going By 25/8/05 By 25/8/05 and on going Immediate and on going On going On going By 25/8/05 and on going Immediate and on going Page 27 Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 26. 38 16(2)(j) The work required in the report by the National Water Treatment Agency in relation to legionella testing requires addressing as a matter of urgency By 25/9/05 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 19 Good Practice Recommendations Both Beeches 1 and 2 would benefit from being made more homely for the residents who live there. Standon Hall Care Home (The Beeches) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Stafford - 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) E51-E09 S22377 Standon Hall Beeches V235523 210605 Stage 4.doc Version 1.40 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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