Inspection on 14/04/09 for Stanley Lodge Residential Home

This inspection was carried out on 14th April 2009.

CQC 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 CQC 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 Lodge Residential Home 16/10/08

Stanley Lodge Residential Home 10/06/08

Stanley Lodge Residential Home 31/07/07

Stanley Lodge Residential Home 03/07/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Stanley Lodge Residential Home School Lane Bay Horse Lancaster Lancashire LA2 0HE Lead Inspector Mrs Marie Cordingley Key Unannounced Inspection 14th April 2009 09:30 DS0000067072.V375391.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanley Lodge Residential Home Address School Lane Bay Horse Lancaster Lancashire LA2 0HE 01524 791904 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Unlimitedcare Limited Manager post vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 23 Date of last inspection 16th October 2008 Brief Description of the Service: Stanley Lodge is registered with the Care Quality Commission to provide accommodation and personal care for up to 23 residents. The home is situated in a rural area of Forton near Lancaster. Stanley Lodge is a detached property set in landscaped gardens and has uninterrupted views of the surrounding countryside. The majority of the residents have been admitted from the surrounding area. There are strong community links, which the management and staff endeavour to maintain. The accommodation comprises 23 single rooms, 20 of which have en-suite facilities. There are two conservatories, a lounge, and a dining room; these communal areas provide residents with a choice of where to sit and who to sit with. All the personal needs of the residents are catered for by care staff. The residents’ general practitioners and district nursing staff manage any medical needs. Chiropodist, dental and optical treatment is arranged for residents. At the time of the visit the information given to the Commission showed that the fees for care and accommodation at the home are from £386 to £465 per week, with added expenses for hairdressing, private chiropody and newspapers. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 5 Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this home is one star. This means that people using the service experience adequate quality outcomes. The inspection of this home included a site visit which was carried out over one day. This visit was unannounced meaning that the manager, staff and residents did not know it would be taking place until we arrived. During the visit we spent time talking with and observing residents and staff, we were joined by the owner of the home later on in the visit. We viewed a selection of paperwork including a sample of residents’ care plans and staff training records. We also carried out a tour of the home viewing residents’ bedrooms and communal areas. A specialist pharmacy inspector carried out a full medication inspection which included examination of the home’s procedures, stock of medicines and all records relating to residents’ medication. As part of the inspection we carried out a case tracking exercise, which involved us looking closely at the care provided to selected residents from the point that they moved into the home. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 7 What the service does well: We spoke with a number of residents during our visit who told us that they liked living at Stanley Lodge and were generally satisfied with the way their care was provided. People spoke highly of the carers at the home. One resident said ‘’The girls are very nice, they are all very kind.’’ Another resident told us ‘’I find the carers extremely pleasant, even when they are busy.’’ We spent the day observing staff and noted that they went about their duties in a pleasant and professional manner. Residents and staff appeared to get along well and people looked relaxed in their surroundings. People are able to look after and take their own medication if they wish and are able to, but the risks should be carefully assessed and monitored. People told us that the quality of food provided was good. One resident commented ‘’I have never had any complaints, its always very nice.’’ However, we did have some concerns about the choices provided for residents which are detailed later in this report. During our visit we carried out a tour of the home and found all areas to be clean, warm and comfortable. The majority of areas were maintained to a good standard and we noted that all residents’ bedrooms were lockable. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? The Service User Guide which provides important information for people considering moving to the home has been updated to provide accurate information. In addition, the guide has been made available in large print. We have made a recommendation in this report that the manager considers other formats so that more people have access to the information. When assessing and planning people’s care needs, the home now obtain a better level of information about the individual’s social history such as previous employment, relationships and valued hobbies and pastimes. This is important information that helps ensure people receive care which is in line with their personal needs and preferences. Medication records have improved although these still contain errors that could place people’s health at risk. The complaints procedure has been updated to provide more accurate information. In addition the procedure is available in large print. The manager is currently looking at other formats to help ensure more people have access to the information. Procedures for the prevention of abuse (safeguarding procedures) have been improved and provide a better level of information for staff. Guidance about what to do if it is suspected that someone had been the victim of abuse is clearer and more detailed. All staff have been issued with updated guidance in relation to whistle blowing. This guidance includes information about their responsibility to report poor practice and an assurance that they will be supported by managers in the event that such a report is made. The number of staff who hold National Vocational Qualifications in care has increased to over half the carers employed at the home. This is a good achievement and means that the home are meeting the national standard in this area. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 9 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home have improved their pre-admission assessment procedures so that carers can provide a more individualised service. EVIDENCE: A Service User Guide is available for people making enquiries about the home. This document includes various information such as the facilities and services provided and information about staffing and daily routines such as meal times and activities. We viewed the Service User Guide and found that it had been updated since the last inspection to include more accurate and up to date information. We were also able to confirm that the guide had been made available in large print. We made a recommendation that the manager explore other formats for Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 12 the Service User Guide, such as audio, so that more people have access to the information within it. The home has improved pre-admission procedures so that a care needs assessment is usually carried out for each person before they are admitted. This is important because it means that carers will have information about new residents and as such, can plan their care from the point that they move into the home. It also means that new residents can be assured that the home can meet their needs and is suitable for them. During our case tracking exercise we viewed one resident’s assessment and noted that this had not been carried out until the day they had been admitted. On further investigation we were advised that the resident had been admitted in an emergency situation. We made a recommendation that the home develop written procedures for emergency admission so that staff know what processes to follow. We also noted that assessments contained a better level of information in relation to people’s social histories and social care needs. This sort of information is important because it helps staff to plan peoples care in line with their personal wishes. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gaps in care planning information could lead to gaps in care. Some aspects of medication handling have improved since the last inspection but there are still examples of poor practice that place the health and well-being of residents at risk. EVIDENCE: Each resident has a care plan in place that details the support they need and how the support should be provided. In general, we found that people’s care plans gave an overall picture of their daily needs. However, we did find some examples where guidance provided to carers was not clear and needed to be more detailed. We discussed our findings with the acting manager and the provider of the service and recommended that care plans be improved so that the help people Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 14 need is clearly stated. This is because gaps in care planning information could lead to people not receiving the help they need. Residents’ daily care records demonstrated that any health problems had been quickly identified by carers and appropriate action taken to ensure that medical advice was sought on behalf of those needing it. Overall we found that there had been some improvements in the way medicines were handled. However, we still had concerns in the way medicines were given and recorded that could result in residents getting their medication wrongly. Staff described administering medication that had been packed down into unlabelled compliance aids to make it easier to take around the home. This is very poor practice that puts residents at risk from receiving the wrong medication. Records for receipt and disposal of medication had improved but there were still some missing records. Records for the administration of medicines appeared well signed but some were still incomplete for laxatives and painkillers so we could not tell why residents had not been given them. We added up medicines and compared them with records. These checks showed that on occasions records were signed but medicines were not given and on other occasions medicines could not be accounted for. We saw medicines that were not given as prescribed by the doctor. For example, a painkiller patch that needed to be changed every three days was sometimes not changed until the fourth day. This means that after the third day there would be insufficient medication to prevent pain. We also saw an antibiotic and a medication for diarrhoea that was not started until three days after it was received by the service during which the resident remained untreated. Residents were able to take their own medicines if they wished and this helped them remain independent. However, the service should ensure that risk assessments are done and reviewed at regular intervals so that any problems can be identified and managed to keep people safe. We checked medicines liable to misuse, called Controlled Drugs, and these were in order. However, the service recorded these medicines in a loose-leaf binder and they should use a bound book with numbered pages to prevent tampering. As examples of poor practice in medicines handling were seen at this visit it is essential that staff are thoroughly and regularly assessed as competent in the task. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home are not provided with regular opportunities to take part in activities they enjoy and are not always able to make choices about what they eat. EVIDENCE: During our case tracking exercise we found that there was improved information in peoples care plans about their individual preferences and preferred daily routines. There was also a better level of information about peoples hobbies, interests and social histories. However, the majority of people we spoke with during our visit told us that activities were not regularly organised. One resident said ‘’There’s very little in that respect,’’ and another said ‘’there are never enough staff on duty to do things like that.’’ Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 16 We viewed records of activities that had been held within the home and some residents’ daily care records. These records didn’t provide evidence that people had been provided with regular opportunities to take part in activities they enjoyed. According to the records there were long gaps, in some cases several weeks, between activities provided for some residents. Minutes of recent residents and relatives meetings showed that people had raised the area of activities and expressed concerns about the lack of variety in activities provided. People we spoke with told us that they were happy with the quality of food provided. One resident said ‘’I can’t complain about the food, its usually very nice.’’ However, when asked if they were offered choices of meals on a daily basis, people did not feel that this was the case. One resident commented ‘’You just have to eat it or do without.’’ We spoke with a number of residents while they were waiting in the dining room to be served lunch. We were concerned to note that none of the residents we talked to knew what was to be served. A resident we spoke with said ‘’They write it on the board occasionally but not very often so you don’t bother looking.’’ When lunch was served one resident commented that she didn’t like the meal. We requested an alternative on her behalf. We also noted that another resident sent his meal back advising a carer that he could not eat the meal as he required a low fat diet. Whilst alternatives were provided for both residents, they had to wait for almost half an hour before their meals were prepared. During this time, others had finished their meals and were preparing to leave the dining room. We discussed our observations with the manager and the owner of the service and expressed concerns regarding the current mealtime arrangements. We have made a requirement and some recommendations in relation to this matter. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with a good level of information about how to raise concerns. EVIDENCE: The home has a complaints procedure in place which is written in a clear and easy to understand way. We were able to confirm that in line with a requirement made following the home’s last inspection, the procedure had been updated and contained accurate information. We were advised by the acting manager that the complaints procedure is available in large print as well as the standard written format. We made a recommendation that other formats be made available such as audio, so that more people have access to the information. All homes are required to have written guidelines in place that staff should follow if it is alleged or suspected that an incident of abuse has occurred. These guidelines are generally referred to as safeguarding procedures. We were able to confirm that the home has these procedures in place. In addition, the procedures had been recently updated and provided a good level of information. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 18 Staff training records confirmed that training in safeguarding had been provided to several carers. We were advised that training was planned for the rest of the staff team in the near future. In line with a requirement made following the home’s last inspection, whistle blowing procedures had been updated and added to the staff handbook. We were also able to confirm that the updated guidance had been issued to all the staff team. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from comfortable accommodation. EVIDENCE: Stanley Lodge is a spacious home and all accommodation is provided on a single room basis. 20 out of the 23 bedrooms have en suite facilities and plans are in place to provide en-suites to the remaining three bedrooms in the near future. There are ample numbers of bathrooms and toilets located around the home. These include a set of three communal, cubicle type toilets on the ground floor. We made a recommendation following the homes last inspection that consideration be given to replacing them with more private, single facilities and have repeated the recommendation in this report. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 20 There are a variety of communal areas for residents to spend their time in, including a pleasant conservatory with a safe accessible patio area, two lounges and two dining rooms. In addition, the home benefits from well maintained and spacious gardens. We carried out a tour of the home and found all areas to be warm, comfortable and clean. We did note that there were some areas that would benefit from general updating for instance, the ground floor bathroom. In discussion the owner of the home explained that there was an improvement programme in place and that all areas needing to be updated would be addressed as part of this programme. We also noted during our tour of the home that locks had been provided on all residents bedroom doors. We were advised by the manager that all residents who wanted a key to their room had been supplied with one. This improvement means that residents benefit from more privacy. The home has infection control procedures in place to help safeguard residents. However, during our visit the manager was unable to produce the procedures. We were advised that a member of staff had taken them home to assist her to complete some work for her NVQ training. We advised the manager that all policies and procedures must be kept in the home so that staff have access to the information within them at all times. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ safety and wellbeing could be at risk if the manager does not monitor recruitment processes properly. EVIDENCE: During our visit we spoke with some residents and the staff members on duty about staffing levels. Carers we consulted told us that due to a recent decrease in the number of people living in the home, staffing levels were adequate. The manager and owner of the home stated that they were keeping staffing levels under constant review in line with residents’ needs. However, residents told us that they felt staff were always very busy and some residents felt that the lack of activities provided was due to staff not having the time to facilitate them. We looked at rotas and these confirmed that there were often only two carers on duty throughout the day. In discussion the owner maintained that this level was adequate due to the home’s low occupancy and that staffing levels would be increased if any more people moved into the home. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 22 We found it very difficult to assess the home’s recruitment procedures because staff personnel files were very disorganised, making information hard to find. Initially, we were unable to locate evidence that appropriate checks such as Criminal Records Bureau disclosures and references had been carried out but with the owner’s assistance we were eventually able to locate this documentary evidence in other places. We explained to the owner and manager that staff files need to be improved and better organised so that evidence of thorough recruitment procedures is available. In addition, the manager needs to have a system in place where she can audit recruitment procedures effectively to help ensure the safety and wellbeing of residents. Since the last inspection of the home, the number of carers who hold National Vocational Qualifications in care has increased to over fifty per cent which is a good improvement. Other necessary training such as moving and handling and safeguarding have not been provided in all cases. However the manager was able to provide evidence that all staff are booked on these courses and would be completing them in the near future. Records of supervision for staff were incomplete in some cases. However, carers we spoke with told us that they did have regular opportunity to meet with their manager on a one to one basis. We advised the manager to ensure that all supervision is carefully recorded and signed by both parties. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality assurances systems need to be improved so that all aspects of the service provided can be monitored. EVIDENCE: Since the last inspection, a full time manager has been appointed and is currently going through the process of registration with the Commission. Throughout the inspection the manager was helpful and cooperative and was able to show some understanding of her role. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 24 We found that a number of improvements had been made to help ensure the safety and wellbeing of people who live and work at the home. However, there are still areas that need to be developed. All the home’s policies and procedures had been updated since the last inspection. However, we did find that they were not all available to view during our visit. For example, the home’s infection control procedures had been removed by a member of staff. It is important that all staff have access to the guidance contained in the home’s polices and procedures at all time. It is strongly recommended that the home’s quality assurance procedures be improved to ensure that there are systems in place to monitor all areas. For instance, records relating to staff recruitment were incomplete and disorganised making it impossible for the manager to ensure that thorough procedures are being followed in this area. We did however note that efforts had been made to include residents and their representatives in the running of the home. For example, regular meetings for residents and their relatives are now held on a regular basis. There is a health and safety policy in place and a number of individual procedures in areas such as fire safety and COSHH (control of substances hazardous to health). Following out last inspection we made a requirement that all staff be provided with training in the key health and safety areas such as moving and handling. We found during this visit that this training had not been provided to all staff, however, those who had not completed it were booked on relevant courses. Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 2 2 Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement It must be ensured that effective systems are in place for the recording, handling, safekeeping, safe-administration and disposal of medication received into the home. This is to help protect service users’ safety and wellbeing. Effective arrangements must be put in place to ensure that secondary dispensing is not carried out and that service users are administered their medication straight from the containers received from the pharmacy. This is to help protect service users’ safety and wellbeing. Effective arrangements must be put in place to ensure that all medication is administered to service users in exact accordance with the prescribers directions. This is to help protect service users’ safety and wellbeing. DS0000067072.V375391.R01.S.doc Timescale for action 15/06/09 2. OP9 13 15/06/09 3. OP9 13 15/06/09 Stanley Lodge Residential Home Version 5.2 Page 27 4. OP9 17 Effective arrangements must be 15/06/09 put in place to ensure that that all medication administration and disposal records are completed accurately and that there is a clear audit trail. This is to help protect service users’ safety and wellbeing. Effective arrangements must be put in place to ensure that any omissions or variations in the administration of prescribed medication and the reasons for these are clearly, legibly and promptly recorded. This is to help protect service users’ safety and wellbeing. Staff must be regularly assessed as competent in medicines handling to ensure that medication is administered to residents safely.(Previous timescale of 17/11/08 not met) All residents should be offered regular opportunity to take part in activities both inside and outside of the home. (Previous timescale of 31/07/08 and 30/11/08 not met). Residents must be provided with meals that meet their individual preferences and dietary requirements. The manager must ensure that thorough recruitment processes are followed at all times to help ensure people’s safety and wellbeing. People employed at the home must be given appropriate training to enable them to carry DS0000067072.V375391.R01.S.doc 5. OP9 17 15/06/09 6. OP9 18 20/05/09 7. OP12 16 31/05/09 8. OP15 16 30/04/09 9. OP27 19 14/05/09 10. OP30 18 14/07/09 Stanley Lodge Residential Home Version 5.2 Page 28 out their duties so that they are competent to carry out their roles safely. (Previous timescale of 30/09/08 and 31/12/08 not fully met (but met in part)). 11. OP33 18 The home’s polices and procedures must be available for staff at all times so that staff have the benefit of the guidance within them. With regards to recruitment, all records as specified in schedule 2 must be kept within the home at all times to demonstrate that the home operate thorough recruitment procedures and so that the manager can monitor this area. 14/05/09 12. OP37 17 31/05/09 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 OP1 Good Practice Recommendations The home’s Service User Guide should be provided in a variety of formats so that everyone has equal access to the information. Written procedures for the admission of people in an emergency situation should be in place so that staff know what processes to follow. People’s care plans should contain more detailed guidance about specific conditions/care needs so that carers know what support should be provided. People should be provided with a choice of main meal on a daily basis and menus provided for residents so that they are fully aware of the choices available to them. 2. OP3 3. 4. OP7 OP15 Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 29 5. 6. 7. OP16 OP18 OP19 The complaints procedure should be provided in a variety of additional formats so that more people have access to the information. All staff should be provided with training in Safeguarding. Consideration should be given to the removal of the communal, cubicle toilets and provision of a more private facility. The home should continue to work through the environmental improvement plans so that all areas are maintained and furnished to a good standard. Staffing levels should be continually monitored and reviewed in line with residents changing needs. Staff files should be better organised and include a recruitment check sheet so that the manager can monitor this area properly. Personal Development plans should be put in place for all staff that record induction and ongoing training. A training matrix should be in place at the home so the manager can monitor training and allocate resources for training effectively. The home’s quality assurance procedures need to be reviewed to ensure that they are effective Results for satisfaction surveys and other quality assurance processes should be published in the Service User Guide. Supervision should be provided on a regular basis for all staff and carefully recorded. 8. 9. 10. OP19 OP27 OP29 11. OP30 12. OP30 13. OP33 14. OP33 15. OP36 Stanley Lodge Residential Home DS0000067072.V375391.R01.S.doc Version 5.2 Page 30 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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