Inspection on 21/05/08 for Stanshawes

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Adequate service.

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 20/08/07

Stanshawes 06/10/06

Stanshawes 19/04/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Stanshawes 11 Stanshawes Drive Yate South Glos BS37 4ET Lead Inspector Melanie Edwards Key Unannounced Inspection 21 May 2008 09:10 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.V360544.R01.S.doc Version 5.2 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.V360544.R01.S.doc Version 5.2 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 www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) To be appointed. Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 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 20th August 2007 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, amenities and social venues. It is a purpose built Home designed to accommodate a maximum of forty-eight residents 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. Fees range between £534- £604. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We (the Commission) met twenty-three of the forty-two residents living at the Home. We met the Acting Manager, the deputy manager, one registered nurse, three care assistants and one of the cooks .We talked with them about roles, responsibilities, training needs, and how they assist residents. We saw staff helping residents with their needs. We saw the lunchtime meals being served. We looked at a selection of records relating to the running and management of the Home. These included four care plans, four assessment records, training records, staff duty records, supervision records, accident records, fire records, and menu plans. We saw most of the environment and the only parts that were not checked were a small number of bedrooms. Sue Fuller, the pharmacist inspector, inspected the handling of medication in the home on 11th June. The Home was operating within the required conditions of registration set down by the Commission. The conditions of registration detail the type of care and the needs of residents, and the numbers of residents who may stay at the Home. What the service does well: Residents are treated with kindness by the staff. Staff work hard to help residents meet their needs. Care Plans generally show how residents’ needs are met. Residents live in a purpose built environment that is overall, well suited to their needs. Staff do a variety of training to enable them to have a good understanding of the needs of residents. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 6 Residents are provided with a well-balanced and varied diet. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 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.V360544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being assessed although assessment records are not being reviewed regularly enough. Residents and their representatives are provided with information to make an informed choice about living at the Home. Residents are not provided with intermediate care at the Home. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home we looked at a copy of the service users guide and the statement of purpose. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 9 Residents are given their own copy of the guide so they have information about life in the Home. The statement of purpose and the service users guide contain information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is also included. The complaints procedure is in each service users guide so residents know how to complain about the service. There is a Four Seasons website that contains a range of helpful information about the service, for people to find out more about the Home. We read four residents assessment records to see how well needs are being assessed. The assessment records were informative, and showed the residents range of physical, mental and social needs had been assessed. The actions taken to support the person had also been recorded in the assessment records. However the assessment records we read were not being regularly reviewed and updated. Assessment records must be regularly reviewed as this information forms the basis for deciding what sort of care and support residents will need. The deputy manager talked to us about how residents’ needs are assessed. They explained that the Home has now re- introduced a key worker system and a registered nurse will be allocated to take specific responsibility for residents nursing assessments and care plan. The Home does not provide intermediate care for residents. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents care plans appear to demonstrate how needs are met. However they are not being reviewed regularly to makes sure they remain current. Residents’ health needs are met. Their health is protected by the medication procedures used in the home. Residents feel satisfied with how the staff treat them, and they feel they are treated respectfully. EVIDENCE: We read in depth four care plans to see how residents are supported with their needs. We found the care plans to be reasonably informative and they showed how to meet the nursing needs of the person. The care plans stated how to meet the care needs of the person. The care plans set out what actions staff must follow to assist the resident to meet their needs. However we saw that there were gaps of time on the care plans of two and three months when they Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 11 had not been formally reviewed or updated by the registered nurses. Residents care plans must be regularly reviewed to show that peoples full range of needs can still be met. We observed the two registered nurses on duty providing leadership and guidance to the care staff they were working with. We also observed both registered nurses spend time with residents. Both registered nurses spoke to the residents and assisted them with their needs in a very patient and respectful way. We saw a health record maintained for each resident. These record when residents see a doctor, optician, dentist and chiropodist and what treatment may be required. There was information in the daily records that demonstrated staff monitor and observe residents and call a doctor if concerned. Residents are registered with local GP surgeries. They are also supported with their health by community nurses, and when needed the community psychiatric nurses. This helps to shows how residents’ health care needs are met. We also received a survey form back from a G.P, and the Doctor confirmed in the form that they were satisfied by the overall standard of care in the Home. We saw staff knocking on bedroom doors before entering them and assisting residents in a polite and respectful manner. This helps demonstrates that staff respect privacy. We observed both registered nurses on duty giving residents their medication. The nurses were calm, and patient with residents and took time to give them an explanation about what medications were for. The pharmacist inspector visited the home on the 11th of June 2008. During this visit we found that procedures are in place to make sure the correct medicines are available for people living in the home. Nurses check the prescriptions and copy them before sending them to a local pharmacy to be dispensed. The pharmacy supplies medicines using a monthly blister pack system. A homely remedy policy has been agreed with the doctors so that registered nurses can treat minor ailments. Staff said that none of the residents are able to look after their own medicines at present. One person is able to do their own blood sugar tests and another person likes to keep their inhalers in their own room, although staff help with giving them. We saw safe storage facilities for medicines and new cupboards have been recently obtained to improve this further. A medicine fridge is available and daily records make sure temperatures are in the safe range. Oxygen cylinders are secured so that they cannot fall over. Suitable storage is available for Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 12 medicines that need extra security. The records for these medicines showed that the stock balances were correct and staff check these every shift change. This shows that these medicines are looked after safely. We saw a large amount of waste medicines, awaiting collection from the waste disposal company. There was insufficient space to store these properly. Staff said that they had spoken to the waste disposal company and asked them to collect the waste. Unwanted medicines, awaiting disposal, must be stored securely in appropriate containers. The home’s medicine policy is kept with the medicines administration record sheets. We saw lunchtime medicines being given on one floor of the home using safe practice. Systems are in place to allow staff to audit supplies of medicines and check that they have been given correctly. Medicines administration records showed medicines are given as prescribed. The pharmacy provides printed medicines administration record sheets. When staff make written additions these are signed, dated and checked by a second member of staff and this is good practice to reduce the risk of mistakes being made. A number of people living in the home had several creams and ointments printed on their medicines administration record sheets, but no record that they were being used. It was not clear if any of these were in current use. Staff must make sure that records are made of the application of all prescribed creams and ointments. Records are kept of the receipt of medicines into the home and of the disposal of unwanted medicines so there is a clear audit trail. Most medicines prescribed to be given When required had clear dosage instructions but some had no guidance about when they should be used. This information was not seen in the care plans we checked. Where appropriate, care plans should include information about the use of medicines given When required to make sure that they always given safely. Staff said that they are reviewing the information kept in peoples’ care plans with a view to improving this. All of the residents that we met told us staff are helpful, kind and caring, when they help them with their needs. The residents also spoke very positively about the respectful and very polite attitude of the staff that help them. Examples of comments made by residents included, ` it’s a good service, and the nurses do respond ’, ‘ the staff are very good ’, ‘ oh yes the staff are all right, they do what I want ’, and ‘ they will do anything for you ’. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in a variety of social and therapeutic activities. However residents’ religious needs should be better respected in the Home. Residents are provided with a well-balanced diet. Residents are able to keep close contact with family and friends if they so wish. EVIDENCE: The Home employs an activities organiser who works for twenty hours a week, as well as an activities assistant who works for one day a week. They engage residents in a variety of low-key social and therapeutic activities such as bingo, arts and crafts, watching old films, and trips to the town. We were told in survey forms that some people feel there could be more social and therapeutic activities put on for frailer residents. Although during the inspection we did observe residents who stay in their rooms have some contact with the activities organiser. She was observed spending time talking to them on a one to one basis. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 14 We saw a religious service take place run by volunteers from a local church with a group of residents .We saw that residents seemed to gain much benefit from the service. However when residents are engaged in a religious service in the lounge this should be able to take place without disruption. We refer to our observation of a small group of staff we saw, sitting chatting on their break during the service, in the dining area of the main lounge. We saw the staff ask residents what their preferred meal choices are for the following day. There are also alternative meal options available if people do not like the main meal options. The menu of meal choices that residents are offered was checked to see if residents are being provided with a varied well balanced diet. We found the menu to be well balanced and varied. . The main meal option was roast pork with roast potatoes and cooked vegetables, or quiche Lorraine, with potatoes and vegetables Residents commented positively about meals and said they thought the food they are offered was, ‘ good ’, or ‘ very good ’. We saw staff help residents who needed extra assistance with their lunch. Residents were being helped to eat their meals in a respectful manner. We saw the staff sit next to residents and spend time talking to them about the meals that they were helping them with. We met a number of residents who were receiving visits from their family and friends. Visitors told us the staff are welcoming and friendly.The Home has a relaxed and flexible visiting policy this benefits residents as this means they can keep in contact with family and friends. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that complaints about the service are listened to and acted upon wherever possible. Staff training and in house procedures help to protect residents from abuse. EVIDENCE: There are copies of the complaints procedure in the reception area. The procedure includes the name of the Commission for Social Care Inspection for anyone who wishes to contact us. However the information is not up to date as it includes our old address. This makes it potentially harder for people to contact us if they need to. The contact details of Four Seasons and the senior manager are in the complaints guide, if people wish to contact them directly to make a complaint. The residents we met told us they would make a complaint to the manager or staff. They said they felt the staff are interested in their concerns and complaints. This helps to demonstrate the Home welcomes and responds positively to complaints. We looked at the complaints record to see how well complaints are dealt with. There had been two complaints received since the last inspection. Both of the complaints related to the service that residents receive, and had been thoroughly investigated by the manager of the Home. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 16 Staff do training to ensure they are up to date in their understanding of the principle of safeguarding residents from abuse. The company also have their own in house training booklet on the subject of how to protect residents from abuse. We think the information in the booklet is relevant to helping staff in the work they do. There is an up to date policy in place relating to the issue of protection of vulnerable adults from abuse. Staff are aware of the policy and the actions they must take to protect residents. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is mostly satisfactorily maintained and mostly suitable for this needs. However the Home is not adequately clean in all parts as there is a strong unpleasant odour in two areas. This makes the environment a less pleasant and enjoyable place for residents to live in. EVIDENCE: We have quoted some of this section from the last report as it still applies: Stanshawes Care Home is a large property built in the suburb of Yate, near Bristol. The Home is built over two floors, which can be accessed by stairs or lift. The building is about a twenty-five minute car ride away from Bristol City Centre. There are local shops a library, a church, pub and Frenchay Hospital is also nearby. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 18 The Home environment was clean and tidy in the majority of areas. As was also the case at the last inspection there was a strong offensive odour present in two toilets in the Home. Action must be taken to make sure that residents live in a Home that remains free from strong and unpleasant odour. We saw that there is a good range of specialist equipment and adaptations in place throughout the Home to assist people who may have reduced mobility. However we also saw that a bath seat in a bathroom downstairs is not currently useable. This must be repaired so that residents can use the bath safely. There are two open plan lounges, one on each floor of the Home. This means residents on both floors have easy access to a lounge area if they so wish. Communal living areas were light, spacious and looked welcoming. We saw that the residents who were sitting in communal areas looked relaxed and comfortable in their surroundings. The majority of bedrooms and all the communal areas were viewed. The majority of bedrooms are for single occupancy, however there are two double rooms. Rooms have been decorated light colours and there are light pastel curtains at the windows. This makes the rooms look more homely for residents to enjoy. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by skilled and well trained staff. Residents can be confident there is regularly enough staff on duty to meet their needs. The Home’s recruitment practices are robust, ensuring staff suitability to work with vulnerable adults. EVIDENCE: We have quoted some of this section from the last report as it still applies: We looked at the staff duty record for two weeks of May 2008 for nursing and care staff .We checked to see if residents benefit from a sufficient number of staff to meet their needs. There is a minimum of two registered nurses on duty at all times and nine care assistants in the morning, as well as an extra care assistant who works a `floating’ shift every morning and helps out where needed. There are six care assistants and two registered nurses in the afternoon. At night there is one registered nurse and five care assistants on duty, including a senior care assistant. The Acting Manager works nine to five hours and a full time deputy manager supports her in her role. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 20 We met catering, domestic, and laundry staff although the numbers of these staff were not reviewed. Based on the evidence from the inspection residents’ needs are being met. We saw the staff who were on duty spend time with the residents, and we noticed that staff have clearly built up close relationships with residents.The residents we met all spoke very positively about the staff who support them. We looked at the training records of three registered nurses and two care assistants to see if they are up to date with their knowledge and practice. There was evidence that demonstrated registered nurses had attended clinical training sessions, and updating over the last twelve months. The care staff have also attended relevant training in the Home. We were told by care staff that a number of them are either undertaking or have just completed the National Vocational Qualification in care award. Four Seasons have their own National Vocational Qualification trainers, who assess care staff at work. To find out if the Home operates safe recruitment practises a sample of staff files were inspected. There are two written professional references taken up for all new staff prior to offering work at the Home. In addition, all staff will complete a Criminal Records Bureau check before commencing employment. These checks are a further safeguard for vulnerable residents. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from having an Acting Manager who will be running the Home in their best interests. Residents and their family and friends are supported to raise concerns to the management of the Home. Staff are not being regularly supervised in relation to the work they carry out in the Home. EVIDENCE: The Acting Manager is a first level registered nurse with many years of experience caring for people with a range of nursing needs. They were the registered manager of another Care Home run by Four Seasons. An application Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 22 has been sent to us for them to be registered manager of Stanshawes Care Home. The staff reported that since the Acting Manager began working at the Home two months ago there have been staff meetings held regularly. This is an opportunity for staff to make their views known to the Acting Manager about how the Home is run. Care staff told us that the registered nurses are very supportive and helpful. However there has been a lack of consistent regular supervision sessions to assist them in their work and in better understanding the needs of residents. When we looked at a sample of supervision records, these showed staff supervision sessions have not been taking place regularly over the last three to six months. Four Seasons have introduced a format for monitoring the quality of the care and the overall service. We did not look at the paperwork that is used to audit the Home on this inspection. However we discussed at length with the Acting Manager their aims and objectives for driving up further the standards in the Home. Based on discussion with the Acting Manager, and a discussion with one of the Company senior manager by telephone it is evident monthly unannounced checking visits of the Home are being done as required by law. However there needs to be up to date detailed and informative records of these visits held in the Home. The records are to demonstrate that the designated individual responsible for the visits spends time with residents and their representatives and observing staff carrying out their duties. An administration assistant helps look after residents finances if needed . We looked at a random sample of three residents finance records.These were up to date and satisfactorily maintained.There is a secure safe to keep residents money and valuables in. Residents’ rights are protected by records that are satisfactorily maintained, up to date, legible and in order. The environment looked safe and satisfactorily maintained throughout. The maintenance man carries out a health and safety audit of the whole environment on a regular basis. A copy of the document that is used to carry out the audit was inspected, and was detailed and aimed to address health and safety areas through the Home. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 23 We looked at a selection of recent accident forms to find out what action is taken after residents have an accident. The accident records showed the deputy manager records in detail the nature of the accidents and what may have caused it. They also monitor all follow up action taken by staff to assist the resident involved in the accident over a period of days after the event. We checked the fire logbook records and it showed fire alarm tests are being carried out regularly and are up to date. There are also fire drills carried out on a regular basis to help protect the health and safety of residents and staff. There is an up to date fire safety risk assessment in place for the home that sets out how to minimise fire risks and maintain the safety of resident’s staff and visitors. The Home won a five star award from the local council environmental health inspectors in May 2007.This helps demonstrate staff follow good health and safety practises in the kitchen when preparing food. The kitchen was tidy and organised when viewed. There were up to date daily records being kept of the fridges and freezer temperatures. This information is necessary to demonstrate the fridges and freezer are working properly and foods are being kept at a safe temperature. The cooks check the temperatures of all high-risk foods before serving the food to residents. This is necessary to ensure the food has been cooked to a safe temperature for residents to eat. There were also dairy products, cooked meats, and cooked food stored in the fridge that had been covered and dated. This is done for these foods so they are used within a safe timescale. Staff who are directly involved in personal care were observed serving food to residents and going into the kitchen wearing suitable protective clothing over their uniforms to minimise the risks of cross infection from their uniforms onto food or surfaces in the kitchen. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 24 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP3 OP7 OP26 Regulation 14.2 15(2)(b) 16.2 (k) Requirement Residents’ assessment records must be reviewed and updated on a regular basis. Residents’ care plans must be reviewed and updated on a regular basis. The two toilets identified at the inspection must be free from strong offensive odour. This is a repeat requirement. All staff must be appropriately supervised. Unwanted medicines awaiting disposal must be stored securely, in appropriate containers. Timescale for action 01/07/08 01/07/08 22/05/08 4 5 OP36 OP9 18.2 13.2 01/07/08 01/07/08 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 OP12 Good Practice Recommendations Residents should be able to engage in religious worship in the lounge without disruption: This recommendation DS0000020253.V360544.R01.S.doc Version 5.2 Page 26 Stanshawes 2 OP9 3 OP9 relates to staff sitting chatting on their break during the service in the lounge. Where appropriate staff should ensure that care plans include information about the use of medicines prescribed, When required. This is to help make sure they are given safely. When several skin preparations are listed on the medicines administration record sheet, action should be taken to make sure it is clear which, if any, are currently used. This is to help ensure that they are used as prescribed. Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Stanshawes DS0000020253.V360544.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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