Inspection on 26/04/06 for Stansfield Hall

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stansfield Hall 30/07/09

Stansfield Hall 10/07/08

Stansfield Hall 16/07/07

Stansfield Hall 13/11/06

Stansfield Hall 17/10/05

Stansfield Hall 14/06/05

Stansfield Hall 07/10/04

Stansfield Hall 14/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stansfield Hall Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH Lead Inspector Diane Gaunt Key Unannounced Inspection 26th April 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stansfield Hall Address Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH 01706 370096 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) Rajanikanth Selvanandan Care Home 22 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (21) of places Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 22 service users to include: up to 21 service users in the category of OP (Older People) not falling within any other category; up to 1 named service user in the category of DE (Dementia) under the age of 65 years) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 17th October 2005 2. Date of last inspection Brief Description of the Service: Stansfield Hall is located approximately two miles from the centre of Littleborough. The home provides personal care and accommodation for 22 service users: 21 aged 65 years and over, and one with dementia care needs, aged under 65 years. The home provides 14 single and 4 double bedrooms, all of which were let as singles at the time of the inspection. Access to the home is up two steps, although there is good ramped access to the side of the home via the conservatory. Grab rails are provided at each side of the steps. All accommodation is on ground floor level. For safety reasons there is limited access to gardens. A small patio area is provided and is used by service users in fine weather. Parking for approximately 8 cars is provided with further on street parking available as needed. There are a number of shops nearby but they are not easily reached by residents. A regular bus service to Rochdale and Todmorden stops close to the home. The most recent Commission for Social Care Inspection (CSCI) report is available in the entrance area and the Service User Guide advises residents and their relatives of this. At the time of this inspection weekly fees were £320, approximately £1387 per calendar month. Additional charges are for hairdressing, chiropody, newspapers, dry cleaning, private telephone line rental/calls, and external activities in the form of a small donation for transport. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on CSCI records and information provided by people who use the service, their relatives, the provider of the service (i.e. the owner) and staff at the home. A site visit to Stansfield Hall on 26 April 2006 took place over 9½ hours. The home had not been told beforehand that the inspector would visit. The inspector looked around the building and looked at paperwork that has to be kept to show that the home is being run properly. To find out more about the home the inspector spoke with six residents, four visitors, three senior carers, two cleaners, the cook, the deputy manager and the provider. The deputy manager was the acting manager at the time of the inspection. Comment cards asking residents, relatives and professional visitors what they thought about the care at Stansfield Hall had been given out a few weeks before the inspection. Five residents, six relatives and a GP filled the cards in and returned them to the CSCI. What the service does well: What has improved since the last inspection? Four double bedrooms had been decorated and let as single bedsits, offering residents more space. One had used the space to house a piano and another had been able to bring a pet cat to live at the home. The acting manager had worked hard to improve training for staff and most of them had completed or updated their health and safety training. Medication training was provided for senior staff who give out medicines and tablets. Record keeping and storage of medication had improved. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Written information about the home was inaccurate in places and copies of terms and conditions were not given to prospective resident to help them make a decision about moving into the home. Residents were assessed before moving in but information from the assessment was not always used to make sure the home was able to provide the care needed. EVIDENCE: A Statement of Purpose and a Service User Guide were written and a copy of each was available in the entrance area. Both the Statement of Purpose and Service User Guide had been updated but there were a number of inaccurate statements that needed to be changed. The Service User Guide was given to each resident when they moved in. Prospective residents and their relatives were told about the home rather than being given written information, they did not therefore have an opportunity to read the home’s terms and conditions prior to moving in. The relatives of a resident due to move into the home on the day of the inspection said that the information they had been given was sufficient to make a decision about whether their relative wished to move there. They knew other people who had lived there and this had helped them Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 9 make their decision. Five residents returning comment cards to CSCI said they had enough information prior to moving in, some had lived at the home for a number of years, copies of Service User Guides were previously given to prospective residents and/or their relatives prior to them moving in. Individual records were kept for each resident. The assessments of the two most recently admitted people were inspected along with information about a person who was moving in later that day. Signed contracts/terms and conditions were held on file for each of the two recently admitted residents. A recognised assessment model was used which covered daily living activities. Each was signed by the prospective resident or their relative and the information was used to write a more detailed care plan. Agreement had been given to the admission of one of the residents even though the home was not registered to provide care in this category. On realising the error the provider contacted CSCI and registration was varied to include the category. At the time of the inspection this resident was satisfied with the care provided. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place but not sufficiently detailed or monitored to ensure residents received the personal and health care they needed. Assessment processes for residents responsible for their own medication were not always completed or reviewed, potentially putting residents vat risk. Residents were treated with respect and their right to privacy upheld in the main. EVIDENCE: Individual plans of care were available and three were inspected. They were based on the assessment made before admission and whilst one written in respect of a long term resident was quite detailed, those in respect of the two most recently admitted residents had notable gaps e.g. social histories, religious observance. All three plans had been regularly reviewed, although not always on a monthly basis. The care plan for the long term resident had been reviewed with the resident on a 6 monthly basis and there was evidence of this on file. However, reviews were not used to amend care plans to reflect changes e.g. deteriorating mobility, changes in continence and in mood. The plans also lacked sufficient detail e.g. moving and handling assessments and falls risk assessments were done but detailed plans to support them were not recorded. The falls co-ordinator had been contacted in respect of one resident Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 11 following the last inspection but the initiative had not been extended to other residents. Other gaps on care plans included detail of District Nurse visits/advice, accident recording and agreed arrangements regarding toileting following a complaint. Care plans were more detailed when inspected at the previous two inspections. During the inspection a resident who rang the call bell for assistance to the toilet was asked to wait until staff returned from their lunch break 30 minutes later. Two staff were needed to assist the resident and only one was not on their break. This is not acceptable practice. All relatives returning comment cards considered they were sufficiently consulted and kept informed with regard to the residents’ care and well-being. GP visits were recorded and residents said the home called their GP when they needed them. This view was supported by information given by a GP who also considered that staff demonstrated an understanding of residents needs. The incidence of pressure sores at the home was low. With the exception of one resident whose toileting needs were not always met, residents and relatives interviewed considered both health and care needs were met. Four residents returning comment cards said they always received the care and medical support they needed and one said they usually did. Residents said chiropodist, optician, dentist and hearing aid specialists visited the home, as and when necessary. Residents were weighed monthly but in one instance no action had been taken with regard to one resident whose weight had fallen 5lbs in two months since admission. Carers handling medication had undertaken a distance learning course and were due to complete a certificated course shortly after the inspection. Two residents administered some of their prescribed medicines but written assessment of safe self-administration was available for only one. Recommendation to expand and regularly review the assessments had not been met. The Medication Administration Records (MAR) examined were generally up-todate but there were some ‘blanks’ where administration or the reason for nonadministration was not recorded. Handwritten MAR entries were not always signed, checked and countersigned, despite recommendation being made twice previously. ‘When required’ medicines were not recorded in residents care plans. Medication storage was satisfactory, the locked cabinet was securely tethered in the office when not in use. Refrigerated and controlled drugs were also satisfactorily stored. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 12 Four people returning comment cards considered that staff always listened to and acted upon what they said, whilst one said they usually did. The majority of residents and relatives spoken with considered residents were treated with respect, although three residents commented on the manner of a minority of staff who were described as ‘impatient’ at times. One resident commented on the embarrassment caused when staff did not provide assistance to the toilet when necessary. At the time of the inspection all residents were living in single rooms and enjoyed the privacy this provided. A number chose to spend the day in their rooms and were not disturbed unnecessarily by staff, although they commented that they liked to chat to staff in their rooms. Those interviewed said staff respected their privacy and dignity when providing personal care. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Provision of social activities had improved but were in need of further development to meet residents social and religious needs. Contact with visitors and the community was actively encouraged. Residents were able to exercise choice and control over their lives. A balanced diet was provided and enjoyed by most residents, but would benefit from review to offer more choices which are to residents liking. EVIDENCE: An activities co-ordinator was employed and worked at the home for 6 hours per week. Discussion with residents and staff indicated activities had improved since the last inspection but that residents would benefit from further development. There was no current record of activities; it was therefore difficult to establish their extent or frequency. Residents said they enjoyed bingo, craft sessions and trips out for afternoon tea at the local Coach House. Live musical entertainment was provided once every 2 or 3 months and was also enjoyed by residents. Staff meeting minutes recorded the need for care staff to provide activities or stimulation to residents when the activities coordinator was not at work. On the day of inspection they spent time manicuring nails and one staff member encouraged a resident to play the organ. Two residents interviewed said they would enjoy more bingo, dominoes and cards. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 14 Social histories, including detail of residents’ interests, were held at the front of some care plans, more recently they had not been completed. Where they were in place they were not used to record how social needs could be met. Care plans did not always record residents’ religion or their wishes with regard to worship. This was particularly so with regard to the most recently completed care plans. Two residents regularly went out to church, one of them was taken by the activities co-ordinator but there were no visits to the home by local religious leaders. At the inspection in June 2005 some residents who were not able to go out said they would like to have a service held at the home. No progress had been made with regard to this request. A key worker system was in place and staff said that as key workers they would buy any shopping residents wanted, check to make sure they had sufficient clothing and accompany them on hospital appointments if they were on duty. All relatives interviewed and returning comment cards considered they were well received when visiting the home. They could see their relative in either communal areas or the privacy of their rooms. The conservatory was available should they wish to visit in private but not use the bedroom. Residents went out into the community either with relatives or the activities co-ordinator and staff. The choices residents made each day varied, dependent upon their mental frailty but residents who were able generally chose what time to get up, go to bed, what clothes to wear, where to spend their day and whether or not to participate in activities. There was evidence of each of these choices being made on the day of inspection. Bedrooms were seen to be personalised – one resident had brought a piano with her which she kept in her bedroom, using it as a bed-sit. The person who moved in on the day of inspection brought her cat with her. The Statement of Purpose included contacts for local advocacy services should residents wish to use them. Two residents managed their own money; others had passed the responsibility to relatives or solicitors. All those spoken with were happy with the arrangements in place. Menus inspected were seen to provide a varied, balanced and nutritious diet. The main meal was usually served at teatime. Food served during the inspection was well cooked and looked, smelt and tasted appetising. Portions were of a good size and some residents were heard to ask for smaller portions that were served without any problems. The majority of residents interviewed and those returning comment cards usually enjoyed the food, one described it as ‘excellent’ and others as ‘OK’. Whilst two choices were offered each mealtime the alternative to the main meal was sometimes salad, which was Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 15 unpopular with residents. This was raised at the last inspection. Although there was a menu’d choice, residents were not always asked for their choice of meal. Jugs of juice or water were provided in lounges and residents rooms, and bowls of fruit were provided in the lounges. Suitable provision was made for those needing special diets i.e. diabetic and soft diets, and staff gave appropriate assistance to those needing it. Residents spoken with who needed to maintain their fluid and food intake for healthcare reasons were aware of the importance of doing so as staff had discussed this with them. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 16 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 the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives knew who to go to with concerns and complaints but effective outcomes were not always achieved. Reporting procedures were not always followed, so residents couldn’t be sure they would receive the necessary protection. EVIDENCE: The home had a complaints procedure. It was on the notice board in the entrance area and on each bedroom door. A complaints book was available in the area outside the office. Whilst this gave residents and relatives the opportunity to record any complaints, it also compromised confidentiality. It had been inappropriately used by a staff member to record a complaint about a resident. The acting manager had addressed the issue with the staff member. CSCI had received one complaint since the last inspection. It was investigated by the provider of the home and not upheld. One area, relating to availability of staff to assist a resident to the toilet during the morning handover, had been discussed with the resident and agreement reached. Residents returning comments cards said they knew who to speak to if they were not happy with the care they received, all but one said they knew how to make a complaint. Residents and relatives spoken with said they raised small issues as they occurred and they were usually dealt with, although two residents said they had complained on a number of occasions about their commodes not being emptied until afternoon and effective action had not been taken. The acting Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 17 manager kept no record of internal complaints for monitoring and quality assurance purposes. Feedback from residents indicated they felt safe living at Stansfield Hall. A procedure for responding to allegations of abuse was available as was an inter-agency procedure. The majority of staff, including the acting manager, had attended Protection of Vulnerable Adult (POVA) and arrangements were in place for more to attend. Staff spoken with had attended (POVA) training and understood the importance of reporting malpractice, and the different types of abuse. Since the last inspection there had been a theft of a small amount of resident’s money. This was replaced by the provider and the police informed – although not immediately. POVA reporting procedures wee not followed. Criminal Records Bureau (CRB) and POVA checks had not been taken up prior to the employment of two current staff. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 18 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 the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main, the premises were clean and adequately maintained and provided a safe, hygienic and homely setting for residents to live in. EVIDENCE: A maintenance and renewal programme was in place and, with a few small exceptions, the premises were adequately maintained. A handyman was no longer employed but residents and staff interviewed said that if they noticed something needed fixing and they told the provider, it was attended to. Nine bedrooms and all communal areas were inspected, provision had improved in that 4 double bedrooms had been redecorated and let as single rooms. They were seen to offer large, airy rooms, which residents had personalised. The following were noted during the inspection and the provider advised: three velour easy chairs were in need of cleaning or replacement, there was no visitor’s chair in room 26, a ceiling tile was in need of replacement in room 2, toilet 15 was awaiting repair and needed new, sealed floor covering, toilet 14 needed a new toilet roll holder, and the staff toilet was used to store combustibles. No action had been taken with regard to the loud call bells in Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 19 one area of the building, and there was also an ongoing problem with water temperatures – this is addressed further in the Management and Administration (Health & Safety) section below. Sufficient aids and adaptations were provided to meet residents needs. The home was odour free and residents returning comment cards said that it was always fresh and clean. This was confirmed by all but two of those interviewed, both of who said that staff did not always empty commodes each morning. With this exception, observation and discussion with staff and residents confirmed there were satisfactory infection control practices. The laundry was seen to be in good order. equipment was provided. It was clean, tidy and sufficient Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff were not always provided to meet residents’ needs. Recruitment and selection practices were unsatisfactory in some instances, not providing sufficient safeguards for the protection of residents. Staff training needed further development to ensure the competence of all staff. EVIDENCE: There had been few changes in the staff team since the last inspection so residents knew them all. Rotas for the week of inspection and 3 previous weeks were inspected. On two weeks insufficient care hours were provided to meet the minimum requirements. On 4 occasions rotas showed that only one carer was on duty between the hours of 9.00pm – 10.00pm although the acting manager and a senior carer said that in each instance a night carer had come on duty at 9.00pm to ensure two staff were on duty. This information was not recorded on the night care rota. Through observation on inspection and telephone contact with the home the inspector was also aware that the manager’s recorded hours were inaccurate. Requirement was made at the last inspection that rotas should record a true staffing record. The manager finished work at 3.00pm and two carers were usually on duty from 3.00pm – 10.00pm. During this time they were responsible for serving and clearing away tea, assisting some residents to eat, helping residents to bed, preparing and clearing away supper and doing the laundry. Requirement had been made that this provision be reviewed by the acting manager and provider. Staff informed the inspector that the hours were raised in the late afternoon/evening when 17 or 18 residents were living at the home, but reduced when the Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 21 number fell to 16. Returned comment cards and interviews with residents, visitors and staff indicated that the need for three staff varied dependant upon residents’ fluctuating care needs, sometimes it was enough, sometimes it wasn’t. Residents spoken to said that whilst response time to call bells was mostly quick, there were occasions when they had to wait for them to be answered. As stated in the health and social care section above, when staff took their breaks together residents who needed two carers for assistance were expected to wait until the break was over. Residents described staff as ‘OK’, ‘very nice’, ‘helpful’ and ‘co-operative’ in the main and that they ‘did their best’. However, three residents commented that some staff were impatient at times. Some staff chose to work 14-hour days on occasion, one relative commented on the risk of staff becoming overtired and not as responsive to residents, although this had not been witnessed. Resident’s comments about some impatient staff may be relevant. Bank staff were employed by the home but additional shifts were offered to day care staff prior to contacting bank staff. Staff who were working long hours had not signed Working Time Regulation disclaimers. Four staff files were inspected. Satisfactory recruitment and selection checks had been made in respect of the most recently recruited staff member but requirement to obtain an up to date Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check in respect of a bank employee had not been actioned. In addition, CRB and POVA checks had not been taken for a kitchen assistant employed at the home for 18 months. Although certificates of training recently undertaken at the home were displayed, copies of these or previously obtained staff qualifications/training were not held on file. Bank staff had not been asked for details of training undertaken at other establishments. An up to date training matrix was available and was used by the acting manager to plan and monitor training provision. The majority of staff had received 3 paid days training in the previous 12 months. The acting manager had increased the provision of health and safety courses and three had begun NVQ courses. Of 15 care staff, 7 had NVQ’s; of which one senior carer had both an NVQ level 2 and NVQ level 3. In-house induction training was provided in the form of ‘hands on’ observation for the first few days of employment. Nationally recognised SkillsforCare induction and foundation training were not provided at the time of the inspection. Training with regard to Protection of Vulnerable Adults (POVA) was planned and ongoing. Four senior staff had been booked onto dementia care courses – this training must be provided for all staff given the recent change in registration to include this category. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management responsibilities had not been fully discharged and residents were not sufficiently consulted about the running of the home. Financial interests were safeguarded. Not all staff were appropriately supervised. Some practices did not promote and safeguard health, safety and welfare of the people using the service. EVIDENCE: The home had been without a registered manager since November 2004. The deputy manager was acting manager at the time of the inspection. She was nearing completion of an NVQ level 4 course in Health and Social Care and was planning to enrol on the Registered Manager’s course in September 2006. The provider visited the home on some weekdays, but the roles of the acting manager and provider were not clearly defined. Some improvement was noted in the management of the home e.g. increase in training provision; minuted staff meetings and supervision sessions. However, the majority of Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 23 requirements and recommendations made at the last inspection, and some made at previous inspections, remained unmet. In particular, shortfalls remained with regard to maintenance of rotas, provision of sufficient staff to attend to residents at all times of the day, reporting of protection issues and ensuring sufficient checks were in place with regard to staff. The provider had begun to send monthly monitoring reports regarding provision at the home to the CSCI shortly before the inspection, but CSCI were not informed of important notifiable incidents e.g. accidents, theft. Residents and relatives knew who the acting manager was and said they would go to her or the provider if there was a matter they needed addressing. Staff, residents and relatives considered the acting manager to be open and approachable but two residents gave examples where the manager had addressed issues with staff, but they had not followed her instruction, leaving issues unresolved. The home has a Quality Policy that is included in the Statement of Purpose, but there was no quality assurance system in place. The provider was in the process of applying for the Investors in People Award. An annual development plan had been written by the previous acting manager and was out of date. Whilst residents and/or their relatives were consulted regarding their care plans on a six monthly basis they were not routinely canvassed for their views about the running of the home either by meetings or satisfaction questionnaires. Questionnaires had been made available to relatives 3 weeks prior to the inspection but none had been returned. A staff meeting had been held in January and a senior carers’ meeting in March. Both were minuted. All residents and relatives interviewed were happy with the arrangements regarding personal monies. The registered provider did not act as appointee for any residents. Where the home had involvement with residents’ monies, appropriate records and receipts were held. Two residents monies were checked and seen to be in order. Discussion took place with the manager as to how the records could be improved. The manager and two senior carers had attended a staff supervision course since the last inspection. Formal staff supervision was provided for staff but its frequency had not been maintained. The aims and philosophy of the home were not discussed in supervision. Those interviewed considered supervision sessions to be helpful and supportive. A senior carer at the home was expecting a baby. She was undertaking lighter duties and only assisted in the moving of residents with the hoist. Whilst this arrangement had been discussed and agreed with the acting manager, a full workplace risk assessment had not been undertaken. Provision of health and safety training had improved and the majority had completed the required courses. The exception was with regard to night care, Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 24 weekend and bank staff who had not updated moving and handling training or fire training. Fire drill practices were only held during the day so a number of staff had not had the opportunity to attend one. The majority of maintenance inspections were undertaken as required. However, the annual gas inspection was overdue and although bath hoists were inspected on the day of the CSCI inspection, the mobile hoist had not been tested since it was purchased approximately 18 months ago. Fire precautions/equipment were regularly tested. Thermostatic mixer valves were said to have been tested by a plumber although there was no written evidence of this visit. Some residents said the water in their wash hand basins was not always hot enough to wash in. A number of water outlets were tested and temperatures varied from 30°C - 50°C. The home’s records showed that on average bath water was 35°C. Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 2 1 Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 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 OP1 Regulation 4&5 Requirement That the Statement of Purpose and Service User Guide are amended and copies provided to residents and the CSCI. That care plans record action required with regard to residents who fall regularly, (previous timescale of 17/11/05 not met) and include District Nurses visits/advice, up to date required action regarding required care and information about social and religious needs. The registered person must ensure that all medication records including those for: Assessment of safe selfadministration Administration are complete, clear, accurate and up-to-date. (Previous timescale of 30/08/05 not met) Timescale for action 31/05/06 2 OP7 15 31/05/06 3 OP9 13(2) 15/08/06 4. OP12 19 Additional activities must be 31/05/06 planned to meet residents’ needs both on a group and individual basis. (Previous timescale of DS0000052796.V288829.R01.S.doc Version 5.1 Page 27 Stansfield Hall 15/09/05 not met) 5. OP18 18 Staff must receive adequate training with regard to protection of vulnerable adults, including use of the Inter-agency procedure. (Previous timescale of 31/10/05 not met) The interagency reporting procedure for the protection of vulnerable adults must be followed. The acting manager must keep accurate rotas for each staff group employed at the home. (Previous timescale of 17/11/05 not met) Sufficient staff must be provided at all times, this to include 3 staff in the evening up until 8.00pm. The home must take a Criminal Records Bureau (CRB) check on the carer who was employed with a CRB undertaken by another agency and ensure all records required by Regulation 19 Schedule 2 are held at the home. (Previous timescale of 31/10/05 not met) SkillsforCare Induction and Foundation training must be provided for staff. Dementia care training must be provided for all care staff. 30/06/06 6. OP18 13 26/04/06 7. OP27 17(2) 15/05/06 8 OP27 18 31/05/06 9. OP29 19 31/05/06 10 OP30 18 31/07/06 11 12. OP30 OP31 18 8 31/08/06 Application to register a manager 15/06/06 must be made. (Previous timescale of 31/08/05 not met) The CSCI must be informed of all 27/04/06 DS0000052796.V288829.R01.S.doc Version 5.1 Page 28 13. OP31 37 Stansfield Hall notifiable incidents within 24 hours of their occurrence. (Previous timescale of 18/10/05 not met). 14. OP33 24 That residents and relatives 31/05/06 views are sought in order to ensure an effective quality assurance and quality monitoring system. (Previous timescale of 31/12/05 not met). Adequate training in moving and handling must be provided for all staff. (Previous timescale of 30/12/04 not met) All staff must attend an annual fire lecture and have at least one fire drill per year. (Previous timescale of 30/11/05 not met). Hoists must be tested by a competent person every 6 months. (Previous timescale of 30/11/05 not met) Thermostatic mixer valves must be serviced to ensure water is delivered at a satisfactory temperature. (Previous timescale of 30/11/05 not met) An annual gas inspection must be undertaken. 31/05/06 16. OP38 13 17. OP38 18 & 23 30/06/06 18. OP38 23 31/05/06 19. OP38 23 31/05/06 20 OP38 23 26/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000052796.V288829.R01.S.doc Version 5.1 Page 29 Stansfield Hall 1 2 Standard OP1 OP9 A copy of the Service User Guide should be given to each prospective resident. The self-administration assessments should be expanded to include details of support needed for identified selfadministered medications. All handwritten MAR entries should be signed and countersigned. The manager should ensure residents’ wishes with regard to religious observance arrangements are catered for. The menu should be reviewed in consultation with residents to ensure they are offered two real choices each mealtime. The complaints should be kept in a more private place and all complaints, however small, should be recorded, along with their outcome. The maintenance issues identified in the Environment section should be addressed. Action should be taken to reduce call bell noise, whilst ensuring it can be heard by staff throughout the building. Sufficient staff should be employed to cover the rota. If, in exceptional circumstances carers work longer than 48 hours per week they should sign Working Time Regulation disclaimers. Staff should receive training to meet residents’ individual needs e.g. dementia care. Regular resident/relative and staff meetings should be held and minuted. All care staff should receive formal supervision 6 times per year, the content of which should be recorded, agreed and signed. All records pertaining to residents and their care should be kept confidentially and in keeping with the Date Protection Act 1998. A workplace risk assessment should be undertaken with regard to the senior carer who is pregnant. 3 4 5 6 7. 8. 9 OP9 OP12 OP15 OP16 OP19 OP19 OP27 10. 11 12 OP30 OP33 OP36 13 14 OP37 OP38 Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Stansfield Hall DS0000052796.V288829.R01.S.doc Version 5.1 Page 31 - 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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