Inspection on 19/04/06 for Stanshawes

This inspection was carried out on 19th April 2006.

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

Stanshawes 21/05/08

Stanshawes 20/08/07

Stanshawes 06/10/06

Stanshawes 03/11/05

Stanshawes 22/06/05

Stanshawes 22/03/05

Stanshawes 16/11/04

Stanshawes 23/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stanshawes 11 Stanshawes Drive Yate South Glos BS37 4ET Lead Inspector Grace Agu Key Unannounced Inspection 19th April 2006 09:00 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 Stanshawes DS0000020253.V291167.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. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stanshawes Address 11 Stanshawes Drive Yate South Glos BS37 4ET 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) 01454 850005 01454 850006 stanshawes@fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Jeen Mary Davis Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 48 persons aged 50 years and over who are receiving nursing care. Staffing Notice dated 04/06/1999 applies Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 3rd November 2005 Brief Description of the Service: Stanshawes is a Company owned home, situated on the outskirts of Yate, in a residential location close to local shops and amenities and social venues. It is a purpose built home designed to accommodate a maximum of forty-eight service users requiring nursing care over the age of 50 years. The home provides accommodation over two floors. There are 36 single and 6 double bedrooms. Whilst none of the rooms have separate en-suite facilities, all rooms have a wash hand basin. There is a lounge and dining room on each floor. All areas of the home are accessible via a lift. The home is set in its own grounds. Car parking is available for several cars. Visitors are welcome to the home at any time. In house activities and entertainments are provided. Mrs Jeen Davis is the registered manager of Stanshawes. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken over nine hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that current and best practice is followed at the Home. Furthermore, the inspection was undertaken in order to review the staff shortages at the home. The Commission for Social Care Inspection was concerned about the frequency of notification of staff shortages sent to the Commission by the Home. At the last inspection, 9 requirements were made and following this inspection it was found that 6 of these requirements were met; three immediate requirements were made at this inspection. A tour of the building was undertaken and a number of records were reviewed; six residents, four relatives and three staff members were spoken with on the day. What the service does well: What has improved since the last inspection? At the last inspection a requirement was made in relation to regular fire drills for staff. Review of the fire log- book evidenced that staff have attended Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 6 regular fire drills and more fire training to ensure that residents are adequately protected. 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. Stanshawes DS0000020253.V291167.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 Stanshawes DS0000020253.V291167.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): 1,2,3, 4,5 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service Residents are assessed on admission to ensure that their needs would be met. EVIDENCE: At the inspection three care files were checked, there was evidence of preadmission assessment to ensure that the home is able to meet their needs. The homes admission policy showed that residents are offered a trial period to enable them to decide whether to stay at the home. Resident’s records viewed contained a letter confirming that the home is able to meet their needs. Terms and Conditions of stay were noted in their files. The Service User Guide contained relevant information for prospective residents. Residents spoken with confirmed that they are happy with the home and had all information before admission to the home Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 9 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): 7,8,9,10,11. . Quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are in place and residents are treated with dignity and respect, however medication administration practices are unsafe EVIDENCE: Three care files were reviewed, each care file contained evidence of pre assessment documentation and individualised Care plans were in place to meet the assessed needs of residents. These care plans were reviewed monthly. Staff interviewed confirmed awareness of needs of residents. One resident stated, “ I will usually get up at 8 am and staff respect that” A tour of the building showed that call bells were within easy reach of the residents to enable them to summon assistance in emergency and when necessary. There was evidence that GP and other health professionals are involved in the care of residents. Residents interviewed stated that they were treated with respect and were enabled to maintain their right to privacy. Staff were noted knocking on the doors and they waiting for a response before going in to attend to the resident. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 10 The home has a confidentiality policy and staff interviewed showed awareness of the importance of keeping residents information confidential. One staff member interviewed described how the staff would normally care for a dying resident. The staff member was aware of the death and dying policy. Medication administration practices were unsatisfactory. Whilst there was evidence of safe disposal and safe administration of controlled drugs, a review of the Medication Administration Record Sheet showed that some medication had been administered but had not been signed for and some medication was signed for but was still in the blister packs and no documented reason was given. These practices put the residents at risk of drug error and an immediate requirement was made to prevent further occurrence. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 11 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): 12,13,14,15 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service Residents’ are provided with meaningful activities and are enabled to maintain contact with families and friends, however staff communication in relation to residents choice of meals must improve and meals presented in a hygienic and dignified manner. EVIDENCE: From a review of the visitor’s book, and from speaking to residents and relatives it was noted that residents are enabled to maintain contact with families and friends. At the last inspection it was noted that there was lack of communication in relation to a change in the menu and choice of meals. A requirement was made and an action plan from the home demonstrated how the requirement was met. However discussion with the manager at this inspection showed that this action plan had not been implemented. The requirement remains in place. . Failure to meet the requirement could lead to enforcement action Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 12 Furthermore, four residents spoken with on the day stated that they were not informed of what was on the menu to enable them to make choices. Staff interviewed is unaware of the difference in menu in the kitchen and the one on the first floor. The menu displayed on the wall in the dining area had no choice of meal for lunch. The chef stated that a new menu with choices had been received from the organisation and that it would be implemented the following week. Observation of lunch showed that the dessert was uncovered between the kitchen and the dining rooms. This is not a good practice as it compromises both the dignity of the residents and food hygiene principles. The kitchen was found to be clean. A risk assessment was in place to protect staff, residents and visitors. Fridge and freezer temperatures were recorded to ensure that food hygiene procedures were being followed. Discussion with the home’s activities person, observation of resident’s activities and a weekly activities schedule seen showed that the home provides meaningful activities for residents to ensure that their recreational interests are maintained. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 13 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 14 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 . Quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and their legal rights are protected however some staff have not received training on Protection of Vulnerable Adults from abuse to ensure that the residents are fully protected EVIDENCE: The home’s complaints procedure and Service Users’ Guide had relevant information to enable the residents to be able to complain. This included information about the Commission for Social Care Inspection that enables the residents to contact the commission if they are not satisfied with the outcome of their complaint. The complaint book had no recorded complaints. Residents spoken with had no complaints and were aware of whom to contact if they had any concerns. Discussion with residents and staff showed that the manager had a good relationship with residents and relatives to enable them to talk about any concerns that they may have. The home has a Protection of Vulnerable Adult from Abuse policy together with a whistle blowing policy and also guidance on reporting of incidents of abuse from South Gloucestershire Council’s Community Care Department. Staff training records showed that staff have received training in this issue. However two staff spoken with have not received Protection of Vulnerable Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 16 Adults from Abuse (POVA) training and their records confirmed this. The manager confirmed that six other staff members have also not received POVA training. It was disappointing to note that the requirement made at the last inspection in relation to this had not been fully met. The requirement remains in place. Failure to meet the requirement could lead to enforcement action. Registered nurses Personal Identification Numbers are verified with the Nursing and Midwifery Council to ensure that residents are adequately protected. Residents spoken with are aware of their legal rights and were enabled to vote using the postal voting system. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 17 Stanshawes DS0000020253.V291167.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, 20,21, 22,24,26 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy a well maintaiined and hygienic environment, adequate equipment is provided to ensure that residents are well cared for. However the home fails to provide sufficient numbers of bathrooms and approppriate storage facilities at the home. EVIDENCE: A tour of the building showed that the environment was well maintained and suited to residents needs. The home’s standard of decoration is satisfactory and creates a comfortable environment for the residents. Residents’ bedrooms viewed looked homely, clean and had small items of personal possessions in individual rooms. Residents spoken with stated that they are happy with their bedrooms and felt safe at the home. Staff responded immediately when residents summoned for assistance. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 19 Staff have received training on Control of Substances Hazardous to Health and Infection Control. All areas seen were free of offensive odour and smelled fresh and clean. Clinical waste was appropriately disposed of. The home’s Maintenance book was well maintained and appropriate action taken in relation to repairs to be carried out was recorded There was evidence of regular hot and cold water temperature checks and other routine checks in line with the Health and Safety legislation. It was noted that two bathrooms were being used for storage of wheelchairs and commodes. Discussion with the manager showed that the manager was aware of this. This is not acceptable. A requirement was made for the home to provide suitable storage facilities for equipment at the home and to ensure that sufficient numbers of bathing facilities are provided for the residents. The Home had adequate equipment to assist residents with their care. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 20 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate numbers of staff mix including at weekends. Its recruitment practices offer protection to residents. Training is well managed in the home EVIDENCE: This inspection followed up a Regulation 37 notification and an answer machine message received from the home in relation to a shortage of staff on weekends. A review of two -weekly rota showed that the home was adequately staffed and had an extra staff member in the morning between 8am and 11am on weekdays and on the weekends. The manager stated that this is to help with breakfast and peak periods. The manager stated that the two occasions that the home experienced shortage of staff were due to sickness and the home was unable to cover. There were adequate numbers of domestic staff on duty to ensure that a good standard of hygiene is maintained at the home at all times. Staff recruitment showed that relevant information was received before commencement of employment. The home’s recruitment policy contained information that offers safeguards to residents. Residents spoken with said that they felt safe at the home. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 22 Staff interviewed demonstrated competency in their jobs, and are aware of their responsibilities, including Terms and Conditions of their employment. New staff have received induction. A review of records and discussion with new staff members showed that some have not attended POVA training. This was previously discussed in Standard 18. The training record showed that staff have received various training including National Vocational Qualification (NVQ) at level 2. The home’s training plan for 2006 showed that various other training will be offered to staff. This will be reviewed at the next inspection. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 23 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 24 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 25 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): 31,32, 33,35, 36 37,38 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and residents are protected through appropriate health and safety practices. However staff are not regularly supervised EVIDENCE: The action plan received following the last inspection in relation to health and safety was reviewed. Evidence showed that staff have attended fire drills. The Fire safety log -book was well maintained. All health and safety checks were up to date. Generic risk assessments are in place to ensure adequate protection of residents. Accidents to residents were recorded and reviewed and where appropriate care plans and risk assessments were reviewed to ensure that needs are adequately met. Various Policies and procedures were in place, relevant and updated. Residents, staff and relatives made positive comments about the manager and Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 26 expressed satisfaction with the overall services and management of the home. One resident stated, “I am happy here, the manager and staff are good”. One relative stated I am satisfied with the care of my relative” Staff supervision records were checked and some staff members have not received regular supervision. A requirement was made to ensure that this happens. Staff must be enabled to express areas of concern in relation to resident’ care and further reflect on their work. Regular supervision is needed to support staff to carry out their responsibilities in providing good care for the residents. Residents’ information was appropriately stored and locked away. Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 27 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 28 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 29 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 30 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 31 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 2 2 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 32 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 2 3 4 5 6 7 Standard OP21 OP15 OP36 OP30 OP22 OP30 OP9 Regulation 23(j) 16(2) (i) 18(2) 18 c (i) 23(m) 13(6) 13(2) Requirement Provide sufficient numbers of bathroom facilities for the residents. Provide residents with varied wholesome nutritious meals Ensure staff are appropriately supervised. Ensure that staff are trained in Communication. Provide appropriate storage facilities at the home. Ensure identified staff receive training on the Protection of Vulnerable Adults from abuse. All medication administered must be signed for and medication records must be accurate Timescale for action 19/05/06 04/06/06 19/05/06 04/05/06 19/05/06 19/05/06 19/04/06 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 Standard Good Practice Recommendations Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 33 Stanshawes DS0000020253.V291167.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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