Inspection on 07/06/05 for Stanecroft

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stanecroft 18/01/07

Stanecroft 07/07/04

Stanecroft 05/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Stanecroft Spook Hill North Holmwood Dorking Surrey RH5 4EG Lead Inspector Kathy Martin Unannounced 07/06/05 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. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stanecroft Address Spook Hill, North Holmwood, Dorking, Surrey, RH5 4EG 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) 01206 854555 Care UK Community Partnerships Limited Jennifer Sharman CRH 50 Category(ies) of SI(E) - Sensory Impair over 65 - 3 registration, with number PD(E) - Physical Disability over 65 - 5 of places DE(E) - Dementia over 65 - 50 OP - Old Age - 50 Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Up to two (2) beds may be used for providing respite care for DE(E) (Dementia over 65 years of age) Up to two (2) beds may be used for people under 65 years old but not under 58 years. Of the fifty (50) registered, five (5) beds may be used for PD(E) (Physical disability over 65 years of age) Of the fifty (50) registered, three (3) beds may be used for SI(E) (Sensory Impairment over 65 years) Date of last inspection 07/07/04 Brief Description of the Service: Stanecroft is a large care home for older people with Dementia situated in North Holmwood in Dorking. The home is on one level and divided into 5 units each running individually to maintain the sense of group living. Each unit has its own kitchennette, dining and lounge areas together with toilet and bathing facilities. The home is generally well maintained and bright. Stanecroft is run by Care Uk Community Partnerships ltd who also run similar establishements in various parts of the country. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced meaning that the residents, staff and visitors were unaware of the visit beforehand. This is the first inspection this year. The home will receive another visit from the CSCI before the end of March 2006. The residents were in their respective units and also in other areas around the home involved in their daily activities. Some residents attended the in house day centre for planned activities and to meet up with each other. The residents in this home had varying degrees of short-term memory problems due to Dementia, which made verbal communication not very easy and sometimes responses to questions asked were not always appropriate. However it was possible to understand from their interactions with each other, staff and residents that they were comfortable and their needs were met. The inspector had opportunity to meet and speak with 2 sets of relatives on the day. The relatives had very good comments about the home and felt that their relatives in care received good care. They praised the staff and the manager and stated that they felt the staff were always ready to help and they felt they were able to talk to them anytime. The inspector spoke to many residents, staff and relatives and also discussed with the manager. The inspector also had opportunity to sit on a staff member’s interview to assess the home’s policies and practices when employing new staff. Care notes were also inspected. The inspector looked around the building. The inspector wishes to thank all those residents, relatives, staff and the manager who largely contributed to the information in this report. What the service does well: Residents’ care needs are met. The residents’ relatives were made welcome and offered assistance for care manager’s reviews and most of all reassurance about the care of their relatives in care especially those newly admitted. Staff are supported via supervision and training. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 6 The senior management of Stanecroft is good at assessing their facilities and obtaining feedback from residents and relatives, staff and the manager. They maintained regular unannounced visits and reported on their findings to the organisation, the manager and the CSCI. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 There are good policies and procedures in place to ensure service users and their relatives are kept informed of the admission and made welcome to the home. Each need is assessed individually involving care managers, family and health care professionals. EVIDENCE: The inspector looked at the documentation notes from two recently admitted residents and discussed these in details with the staff which was backed by the discussion with one set of relatives (relating to one of the set of notes). Admissions are as much as possible planned well beforehand and the manager stated that after several issues in the past, the staff are now more assertive in being very thorough in their assessment of needs as they have no registered nurses there and are not registered to take residents with high and complex needs. This ensures the right criteria of residents get admitted to the home and is less disruptive to all those other residents in care in Stanecroft. The home manager involves several health care professionals in her decision making together with the staff and relatives and the residents. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 9 An assessment is completed which lists all the different areas of needs clearly together with any risks involved, challenging behaviour, sleeping patters and medication. Also seen were details of physical, emotional, mental and psychological needs. Residents, care managers and relatives are encouraged to visit the home as often as they liked to familiarise themselves and also to meet staff and other residents, ask questions and share a meal. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The residents have an individual care plan which states all their needs and what staff did for these needs to be met. There have been issues in the past that have made it difficult for the staff to fully meet some of the needs of residents due to inappropriate placements although this is now much improved. EVIDENCE: The inspector looked at care plans and spoke with the staff about the care plans. Staff are allocated a group of care plans to maintain and update regularly. The care needs are clearly set out in those plans and include emotional and psychological needs. Also present is information from a range of health care professionals who also provide care for the residents in Stanecroft. Also included in the care plans are risk assessments for pressure sores, falls and moving and handling. There are regular care managers’ reviews when meetings are held in the home with the resident and their supporters to check on how well the resident is settling in and discuss further plans. On occasions when there have been problems with inappropriate placements the CSCI had been informed for advice and appropriate reviews of care have Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 11 been organised to resolve issues relating to the placements and other placements sought if the home is unable to meet the residents’ needs due to them not meeting the admission criteria. These were well managed. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 There are organised activities in house. Service users are encouraged to participate and maintain contact with relatives and friends. The arrangements for catering were reasonably satisfactory. EVIDENCE: The home has a new activities organiser due to start work in two weeks’ time. She is receiving induction training in another Care UK home in the county. In the meantime the home has allocated a carer on a daily basis to organise activities for residents. Events are displayed on notice boards and the main entrance for relatives and visitors to also see. The home regularly invites external entertainers such as the animal farm and a pianist. Outings to the local pubs for lunch are not uncommon. Families and friends are reported to take residents out. The home also organises barbecues and high teas to which relatives and friends are invited. There is a fully functional day centre attached to Stanecroft that serve the local community. Some 5-10 residents regularly attend daily for some part of the day to socialise with the others and join in day centre activities such as craft, quizzes or other activities. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 13 The inspector was able to observe the interactions between the residents on the day, which was mostly friendly. Many residents looked out for each other and guided each other at the table or whilst taking a seat in the lounge. There have been occasions when residents’ behaviour became an issue due to their illness and have disrupted the calm and friendly atmosphere. Staff have so far done well to ensure residents’ rights were protected in the most proactive manner and also with close involvement of family and other health care professionals. The home employs a kitchen cook to prepare the breakfast and evening meals and other accompaniments to the main meals of lunch times. A year ago the home introduced chilled cooked meal delivered straight to the home after the menu orders are taken beforehand. These are cooked in special trolleys and distributed individually to the residents by the home staff. The manager stated that this arrangement was working well. She was particularly impressed by the calorie counts, which ensured a balanced diet of protein, high fibre and carbohydrates was maintained when menu planning. Special diets such as low salt, high protein or diabetic diets can also be provided very easily. There are a large variety of meals on the different days and an alternative to the main meal is provided. The inspector asked the residents in the different dining rooms what they thought of the food. They stated that they liked the food and it tasted nice. The meals were plated attractively. The mixed vegetables served on the day however appeared overcooked and discoloured. The inspector did not sample the food on the day. Residents can have a snack and beverages any time day or night. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 a 18 There are policies and procedures for the home to deal with complaints and ensure the protection of vulnerable residents. EVIDENCE: The home has a complaints procedure, which is mostly used by relatives rather than the residents. The staff were keen to resolve any issues promptly. The procedure is clearly written and copies are given to all residents, staff and visitors. The manager aims to see the residents and relatives very often. The inspector did observe that she was approachable towards the residents and the relatives, which was confirmed by a visiting relative. The home uses the Surrey Multi Agency Policy and Procedures to assist them to deal with any cases of suspected abuse. The home provides regular training for all staff about the protection of vulnerable persons. The home staff have promptly referred any suspected cases of abuse or potential abuse appropriately to the relevant professionals and kept the CSCI informed at each step. It is fair to state here that the cases mentioned were in connection with fellow residents’ behaviour towards each other and bouts of aggressive behaviour due to their illnesses. These were dealt with in a very sensitive and proactive manner by the staff. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 a 26 The home was well maintained and provided a safe, clean and friendly environment for residents. EVIDENCE: There is a number of internal improvements to the lighting and general décor which has taken place over the last few months. Further internal decoration is planned. The manager reported that repairs are undertaken promptly. A budget is available for the purchase of new furniture, curtains and bedding for the exception of bedroom furniture. The manager has already been selecting the new items. A new washing machine will be in place to replace the broken one soon. There is a team of staff responsible for keeping the home clean and hygienic. The cleaning hours have now been increased for this important work to take place regularly. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 16 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) 29 a 30 The recruitment policies are sound. Staff are offered a range of training to help them do their jobs in a competent and knowledgeable manner. EVIDENCE: The inspector was able to observe the interview of a candidate. There was preparation beforehand and a clear procedure that the manager had to follow. Equal opportunity practices were followed. It is recommended that the manager received formal training in selection and recruitment to enable her to obtain up to date knowledge and skills in this task, as she had not received any formal training in this matter before. Relevant staff details are maintained in each staff files in accordance with regulations such as a clear criminal records bureau checks. Similarly those staff who are employed by an employment agency and then sent to the home also have a file in the home with the relevant personal details including a recent photograph. This ensured the safety of the residents. Staff received a range of relevant training to help them perform their jobs. This included manual handling, First Aid, Basic Food Hygiene, abuse awareness, fire and heath and safety. All staff received induction training. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 17 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) 38 Health and Safety policies and procedures in the home were taken seriously. Staff received training on those to ensure the safety of all those present. EVIDENCE: The home has all relevant policies and procedures in place. Equipment are replaced if not repaired promptly. The new washing machine will be in place to replace a broken down one. There are monthly checks on the premises and health and safety in general which are recorded in the Regulation 26 reports, which are copied to the CSCI. Staff received training in all aspects of health and safety. Residents’ care are planned in a risk assessment framework which means that every risky task undertaken by residents are clearly written with exact details of what staff do to minimise the risks. Accidents and incidents are reported appropriately to residents’ relatives and their care managers and also the CSCI. Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 18 Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 19 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 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Stanecroft h09-h58 s28739 Stanecroft v231413 070605 stage 4.doc Version 1.30 Page 20 no 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 Regulation Requirement Timescale for action 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 29 Good Practice Recommendations The manager to receive formal training in the recruitment of staff for her development. 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