Inspection on 25/08/05 for Stanley House

This inspection was carried out on 25th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stanley House 05/09/07

Stanley House 02/10/06

Stanley House 12/12/05

Stanley House 13/10/04

Stanley House 21/07/04

Stanley House 11/11/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Stanley House 155 Duffield Road Derby DE22 1AH Lead Inspector Gail Meads Unannounced 25 August 2005, 9.30am th 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. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stanley House Address 155 Duffield Road Derby DE22 1AH 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) 01332 364734 Willover Limited Susan Buckby Care Home with Nursing 42 Category(ies) of Older People 42 registration, with number of places Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/10/04 Brief Description of the Service: Stanley House is a 42 bedded Care home providing nursing care situated in a residential area of Derby and close to a range of shops and local amenaties. The property was originally a private dwelling that has been converted and extended. Residents rooms are located over three floors, all floors are accessed via a passenger shaft lift or staircase. The home provides limited en-suite facilities. There are a variety of communal areas made available for use at all times. The gardens areas are landscaped and accessible to residents. The home provides 24 hour staff care three meals per day with drinks and snacks provided at regular times throughout the day, personal laundry and range of health services and social and leisure activities. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a four hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including residents’ care files, staff files and records, time was spent looking around the building and speaking to a number of residents, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the care arrangements for the two residents for the purpose of case tracking. What the service does well: What has improved since the last inspection? The kitchen area has been refurbished. The recruitment process has improved. A residents’ information guide has now been developed and each resident has been provided with a copy. Quality assurance systems have now been developed, questionnaires are provided to relatives and residents, one to one interviews with residents, audits are carried out which include monitoring the meals provided and staff qualifications. A document is provided giving feedback from the information gathered. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 6 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. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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 Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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) 1.2.3.4.5. The admission and assessment process was clear and accessible, however information held on staff was not available for inspection. EVIDENCE: The home’s Statement of Purpose was examined and found to need up dating as it still refers to the National Care Standards Commission. Detailed needs assessments were in place at the point of being offered a place within the home. The documents seen during the inspection demonstrated evidence that residents and their relatives had been involved in the process. Trial periods are offered to potential residents. A residents’ information Guide has now been developed and each resident had been given a copy, a copy of the Statement of Purpose and Residents’ information Guide were also displayed on the homes notice board. Residents’ files examined for the purpose of case tracking were well structured and the information held was easily accessed, although the risk assessments Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 9 completed for nutritional scoring and waterlow did not indicate what action must be taken when risk was identified. This was documented in the residents’ care plan this system did not enable a clear indication of the process followed. Residents were provided with contracts/terms and conditions within their Residents’ Information Guide. Intermediate care is not provided at this Care Home. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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) 7.8.9.10.11. Individual care plans have been developed enabling the staff involved with residents care to provide consistent levels of support, hence the welfare and safety of residents is maintained. EVIDENCE: For the purpose of case tracking two residents’ files were assessed detailed and informative individual care plans were in place. The care plans assessed were clearly based on the needs assessment and ongoing information was being recorded as required. The residents themselves were involved in preparing the care plans this was indicated with their signature at the end of their individual care plans. Residents were able to access a wide range of health services including dental care, chiropody, eye and ear test are provided as and when needed. All the residents have a general practitioner. All health visits are recorded. Medication records for the safe keeping and administration were examined and found to be satisfactory, although it was evident that some prescribed Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 11 medication was shared. The home also has two residents who need insulin and there was no maximum minimum thermometer being used. Records were maintained for the controlled drugs and all medication had been recorded on receipt, the staff dispose of all unwanted drugs hence there is no drug disposal record maintained. The manager stated that two qualified staff carry out the disposal of unwanted drugs. Residents spoken to stated that their privacy and dignity was upheld by staff. One resident said “staff are very kind and I feel they do respect me at all times”. The funeral arrangements for residents are identified as part of their individual care plan, the two files assessed during this inspection indicated that residents were involved in giving staff this information, one resident had refused to talk on this subject and this had been recorded. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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) 12.13.15 Residents are given the opportunity to take part in a number of leisure activities, however many of the residents are still unmotivated and uninvolved. The food provided is varied but not well presented. EVIDENCE: The home provides a range of leisure activities, a programme of activities is in place, however it was noted that a number of residents did appear unmotivated and uninvolved one of the residents spoken to confirmed that activities were provided and that residents could choose to be involved or not. Residents are given information to enable them to make informed choices about their care. The lunch period was observed and found to be both calm and relaxing; the dining area was well presented. Menus had been developed and were displayed where residents could see them; the food provided is varied and nutritionally well balanced. However the food on the day of the inspection looked unappetising and had been in the heater for too long a period. Residents spoken to stated that the food was good and no complaints were expressed. The food provided was discussed with the sister in charge who stated that the chef was due to leave and the issues raised would change as a result. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 13 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) 16.18. Complaints are dealt with appropriately and promptly. Staff understand the causes of abuse and know how to report any concerns they may have. EVIDENCE: The complaints record was examined there had been one complaint recorded, it had been dealt with within eight days and the letters were attached to evidence that the complaint had been dealt with to the satisfaction of all parties concerned. It was noted that there had been a complaint made of which the Commission for Social Care inspection had been aware of but there was no record of this complaint in the record book. Staff spoken to confirmed that they had received Adult Protection training and that they had no concerns about the abuse of residents. Staff were able to demonstrate a good understanding of the nature of abuse. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 14 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) 19.20.21.23.24.25.26. The home presents as warm, light, clean, quite ‘homely’ and comfortable. EVIDENCE: A number of random bedrooms were assessed and found to meet the requirements as identified in Standard 24. Residents’ bedrooms were clean light and warm no offensive odours were detected. Residents’ rooms were personalised and items of their own furniture and personal possessions were in evidence. There are a suitable number of toilets and bathrooms provided. The sluice facility is still in need of refurbishment and this was identified in the last inspection report dated 13/10/04. Residents are able to move around the home safely, there are two lifts provided, corridors are wide enough for wheelchairs and a range of hoist and toilet and bath aids are supplied. It was noted that a nasty accident had occurred whilst a resident was being bathed and the bath chair had been the causation of this accident, the bath chair was still in place and being used. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 15 The communal areas provided are furnished in a comfortably and ‘homely’ manner, there is wheelchair access provided to the garden area and seating is available. The lighting provided is domestic in nature, the home is warm, windows throughout the home could be opened and restrictors had been fitted to residents’ windows. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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) Unable to assess these Standards as the staff files were locked and only the matron can access the information. EVIDENCE: The inspection took place on the matrons day off, the sister in charge was unable to access staff information. Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 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) These Standards were not assessed during this inspection. EVIDENCE: Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 18 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 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 x 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x x x Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 19 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 OP1 Regulation 6(a) Requirement The registered person must ensure that the homes Statement of Purpose is updated. The registered person must ensure that the prescibed medication for each residents is obtained and administered to them. Medication must not be shared. The registered person must ensure that a minimum maximum thermomitor is used in the medication fridge both temperaturesmust be recorded The registered person must ensure that a record is maintained of all drugs disposed of within the home. The registered person must ensure that food prepared for residents is served as soon as possible to the time is is cooked. The food provided must be presented in such a way as to be appetising for residents. The registered person must ensure that all complaints made are recorded fully in the complaints record. The registered person must Timescale for action 01/10/05 2. OP9 13(2) 01/09/05 3. OP9 13(2) 01/10/05 4. OP9 13(2) 01/10/05 5. OP15 16(2)(i) 01/10/05 6. OP16 17 Schedule 4 (11) 23(2(b) 01/10/05 7. OP26 Was Page 20 Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 refurbish the upstars sluice area. 8. OP24 23(2)(d) The registered person must ensure that all damaged paintwork to doors and skirting boards are repainted. The registered person must ensure that the equipment provided to bath residents is safe. The registered person must make available all the required records for inspection. 30/06/05 now 01/01/06 30/12/05 9. OP21 13(4)(c) and 13(5) 17(3)(c) 01/10/05 10. OP27 01/10/05 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 Good Practice Recommendations Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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 Stanley House C02 C52 S2110 Stanley House V245717 250805 Stage 4.doc Version 1.40 Page 22 - 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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