Inspection on 22/06/05 for Stanshawes

This inspection was carried out on 22nd June 2005.

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

Stanshawes 21/05/08

Stanshawes 20/08/07

Stanshawes 06/10/06

Stanshawes 19/04/06

Stanshawes 03/11/05

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 Announced 22 June 2005 09:30 nd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stanshawes Address 11 Stanshawes Drive Yate South Glos BS37 4ET 01454 850005 01454 850006 stanshawes@fshc.co.uk Laudcare Ltd (wholly owned susbsidiary of Four Seasons Health Care Ltd Mrs J M Davis Care Home with Nursing for Older People 48 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of OP Old age for 48 registration, with number of places Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 22 March 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 Davis is the registered manager of Stanshawes. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over fifteen hours and was carried out in response to complaint received by the Commission for Social Care Inspection in relation to poor standard of care at the home. The Inspection was also undertaken to review the requirement made at the last inspection also to review the care practice to ensure it is in line with the legislation and that best practice is followed at the home. At the last inspection eleven requirements and three recommendations were made. It was disappointing to note that four of the eleven requirements made have not been met. Generally, the home was found warm, well lit and tidy. The residents were found to be relaxed and looked well cared for in their homely environment. Manager and staff were noted interacting with the residents in a respectful and dignified manner. A tour of the building was undertaken and a number of records were viewed. Five residents, five staff and two visitors were spoken with. What the service does well: Prospective service users are assessed before admission to the home to ensure that the home is able to meet their needs. Prospective service users are aware that they are able to move into the home on a one month trial basis to ensure that they are satisfied with the care provided. Care plans are developed for individual service users and are reviewed monthly. Good nutritious meals are provided for residents and are not hurried and those unable to feed themselves are fed in a sensitive and dignified manner. There are on-going training courses to enable staff to meet individual residents’ needs and ensure residents are protected from harm and abuse. Aids and equipment are provided in sufficient quantity to assist care staff in meeting resident needs. The environment is well maintained, tidy and safe, giving the residents a sense of homeliness and security. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Over the last three months the Commission for Social Care Inspection has received a complaint in relation to poor standards of care at the Home. This complaint was investigated by the Provider, however, the complainant is not satisfied with the outcome and has requested that the complaint be investigated by the Commission. The Manager must ensure that the concerns set out below are addressed: Maintaining the cleanliness of the Home including carpets, to ensure that offensive odours are eliminated, needs to improve. Facilities for service users would be improved if bathrooms are not used for storage and kitchen equipment is in good working order. Residents would be better protected if all staff attend the drills at least twice a year. Residents would be protected from abuse if satisfactory references and Criminal Record Bureau disclosures are obtained before staff members commence employment. Residents would be better protected if staff receive training on abuse. Following prescribed action on the care plan would enable the staff to meet the needs of the residents. Ensuring that doors are not wedged would protect the residents in the event of fire out break. Ensuring that appropriate numbers of experienced staff are working at the home at all times would enable the staff to meet the residents’ needs. Spread of infection would be minimised if staff dispose of aprons and gloves after attending to a resident. Also, ensuring that aprons and gloves are stored in the room of a resident with MRSA and are disposed of in the yellow bin provided. Furthermore, that a cushion in one resident’s room is kept clean at all times. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 7 Residents would be at risk if the call bells are not within easy reach to summon assistance in an emergency or for basic need. Residents and their families and friends would feel reassured if it is confirmed in writing that the home is able to meet their needs on admission. Care of residents would improve if quality assurance system that captures the views of the residents, families, friend and other professionals are in place. The home would be in better condition if the kitchen is repaired or replaced. Residents would receive better care if staff are regularly supervised. Residents nutrition would improve if meals are improved and fluids intake is provided according to written instructions. Resident would be better protected if all their information are kept confidential. 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 D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. Information is provided as process of admission of prospective residents to enable the resident to make a choice of moving to the Home. However, it fails to provide assurance that their needs will be met and the Terms and Conditions of their stay at the Home. EVIDENCE: The Homes’ Statement of Purpose and Service User Guide contained detailed information about services and facilities provided at the Home, including complaint procedure which contained information about the Commission for Social Care Inspection to enable the service user to contact the Commission if not satisfied with the outcome of their complaint. However, no Terms and Conditions are provided to the prospective resident in relation to the fees to be paid and other conditions of their stay at the Home. This requirement had been made previously and Manager stated that the matter is being dealt with by the Head Office. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 10 Two care files, of recently admitted residents, contained pre-admission assessments and care plans completed on the how the assessed needs were to be met. One resident/relative consulted confirmed that the Manager visited him/her at the hospital before admission. The relative stated that he/she visited the home with his/her daughter to view the Home and was made aware of the one month trial period. Although there was no documented evidence seen confirming that the Home is able to meet the service users needs, the relative stated that the Manager informed them verbally that the Home is able to meet their needs. Staff spoken with stated that they are aware of the new resident and are able to meet their needs. The Manager is required to confirm in writing to the resident that the Home is able to meet their needs in respect of their health and welfare. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11. The Home offers care and support to service users, however records fail to demonstrate how the home protect the care needs of service users. EVIDENCE: Ten care files were reviewed. There was evidence of pre-assessment before admission to the Home. All the care files had identical core care plans in place developed by the Home. Specific individualised care plans are developed when the need arises. Two residents on PEG feeds had a comprehensive care plan and feed regime to be followed by staff. There was a regular input by the nutritionist at the hospital. The care plans were regularly reviewed. However, one service user admitted in January 2002 with episodes of wandering recorded, had a care plan of how staff are to meet the needs, however, there was no evidence recorded of how the resident was being supervised. There were entries on 8th June 2005 of “wandering a lot” and wandered into a residents room on 16th Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 12 June 2005. There were entries on 21st May 2005 and 16th June 2005 that the resident ‘hit’ two staff members and one staff member respectively. There was no evidence of referral to other health professionals in relation to this behaviour. The Manager stated that two senior care staff members have attended training on Challenging Behaviour and are expected to train other staff members. Another resident with a wound on the sacrum had a detailed care plan about dressings to be used and this was regularly reviewed. However, there was no care plan in place in relation to difficulty with chewing along with oral hygiene after meals and communication as stated in the transfer note from hospital/social services care plan. One resident’s Manual handling assessment had not been reviewed for two years (2003). The Manager stated that staff are aware of what to do but have no time to do them because of workload! There was no care plan in place in relation to a resident with MRSA however, yellow and red bins were noted in the room to dispose of the aprons and gloves and collect dirty clothes for washing respectively. An antiseptic gel was noted outside the bedroom on a hand rail. The cushion in the room was noted to be dirty, the nurse in charge quickly organised the cleaning of the cushion. One resident’s suctioning tube was noted unprotected on the floor in the room exposing the resident to potential infection. The Manager is required to ensure that specific care plans are in place to enable staff to meet individual residents needs. Further more that all measures are taken to minimise risks. Other care files viewed had care plans in place on how needs are to be met and are regularly reviewed. One service user spoken with stated that she/he is well cared for at the Home, another resident stated that staff respect him/her. Two residents stated that they are able to get up when they like and retire when they want to. One stated, I would go to bed early if “I wanted but I have to stay up to take my tablet”. There was evidence of visits from other health professionals to include GP, District Nurses, Chiropodists and Nutritionists. Staff were noted knocking at the doors before going into residents rooms, and spoke to the resident in a dignified manner. One resident stated that staff treat him/her well. One visitor consulted does not feel that the standard of care is good but feels that the staff are working hard. The visitor stated that staff talk about residents at the home openly. The Manager is required to ensure that staff are aware of confidentiality of information about residents. Medication administration was checked and was satisfactory. There was evidence of receipt and disposal of medication in place. The controlled drugs were properly recorded and signed by two Registered Nurses and the balance was correct. The Registered Nurse on duty stated that the medication of a deceased resident is usually kept at the home for seven days before disposal. The Home has a Death and Dying policy. One service user’s file viewed contained information on her/his wishes in the event of death. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Residents are supported to maintain contact with family, friends and local community as they wish, however, the Home fails to provide varied activities and choice of meals. EVIDENCE: Residents spoken with at the Home said that they are enabled to maintain contact with their families and friends. One service user stated that she was expecting her/his two sons this weekend. Another service user stated that her/his daughter and son took him/her to London two weeks ago to see his/her grandchild. She/he enjoyed the weekend. Visitors book contained evidence of visits from families, friends or representatives of the residents. Some visitors were noted visiting the Home on the day of inspection. Home’s activities programme was examined and the forthcoming activities are noted as follows for the week 20th – 24th June. Monday, Bingo upstairs, Tuesday, Bingo downstairs, Wednesday, Beetle Drive, Thursday, floor games upstairs, Friday, quiz and shop. A group of eight residents were noted playing Bingo in the marquee provided in the grounds. Some residents spoken with said they enjoyed the game of Bingo. Four Seasons Health Care provides a social assessment as part of the admissions assessment to enable staff to plan individual activity based on residents capability. This form was completed and Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 14 noted on residents’ files, however, there was no evidence of record of participation in activities noted in the residents files. There was no documented evidence of how the residents who preferred to stay in their rooms were engaged. The Home Manager is required to consult with the residents in regard to activities organised at their home. It was agreed that a list of residents who participated in each activity is kept at home and regularly monitored to ensure that all residents benefit and are monitored. One visitor spoken with stated that residents would benefit from going out in the garden when “the weather is good” to have some fresh air. Another service users said she watches the birds from her bedroom. A bird cage was noted outside his/her bedroom. This is commendable. Residents spoken with stated that they have a choice of when to get up and when to retire. One service user stated she/he got up at six am because she/he wanted to. She/he stated that “I don’t like to get up late”. The resident stated that she/he retires at 10pm because she/he prefers to stay up and take her tablets first. The resident stated that she/he would like the hedges cut down so she would be able to look out from his/her window. The two week menu was reviewed and there was no choice of meals noted at lunch. The meals noted on the days of inspection looked nutritious and well balanced. The Home Manager stated that alternatives are provided if residents are not happy with what was on the menu. However, residents consulted on the day of inspection had different views about the food provided at the Home. One service user stated that she/he did not enjoy the meal because it was “children’s food, small portions of food with few frozen vegetables”. Two residents stated that “food is okay”. There was no fresh fruits noted either in the kitchen or on the dining tables for the residents. Staff were noted assisting residents and those who were unable to feed themselves were fed in a sensitive and dignified manner. One resident stated that the food is varied but always cold and would like the food to be hotter. She/he stated that she/he has drinks at 10am, 1pm, 3pm, 5pm and has Horlicks at 9pm. One service user with instructions in his/her room to be fed drinks and food had a beaker of tea with a straw left cold on the table in his/her room. This was brought to the attention of the nurse in charge who stated that she would ensure that this did not happen again. The Home manager is required ensure that procedure is in place for service users to receive adequate fluid intake. The kitchen had risk assessment for various equipments and the kitchen environment, the fridge and freezer temperature was regularly recorded and food in the fridge was labelled. An officer from the Environmental Services had visited on 15th June 2005 and is yet to provide a report following the visit. The kitchen floor was found unclean, the Chef stated that the kitchen was regularly mopped, however, the floor requires attention, either to be replaced or deep cleaned. A pool of water was noted under the dishwasher in the kitchen due to a leak. The Chef stated Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 15 that it has been reported to the Manager. The Home is required to ensure that kitchen equipment is in good working order. The Chef stated that she had attended NVQ 2 in catering and had food hygiene certificate and receives regular supervision from the Manager. The Kitchen Assistant also has a food hygiene certificate. The food was noted being served from the hot trolley. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 standard(s) 16,18 Residents are enabled to complain, however, the Home fails to protect them from abuse through its practices. EVIDENCE: The Home operates a comprehensive complaint procedure. One complaint recorded showed evidence of correspondence between the Home and complainant on how the issue was resolved. The Commission for Social Care Inspection received a complaint about Stanshawes in relation to poor care practice. The complainant is not satisfied with the outcome of the investigation by Four Season’s Health Care and has requested the Commission to carry out its own investigation into the issues raised. The Home has a communication book to encourage relatives to write about any concerns they might have about the Home. The last entry noted was November 2004. Residents spoken with stated that they would approach the Manager if they have any concerns. The Home has a policy and procedure on Prevention of abuse of vulnerable adults. There is evidence of staff training on abuse. However, one staff member employed 6th December 2004 had no CRB, another staff member employed in February 2005 had no POVA First check and no CRB disclosure. These staff members were not working under supervision. The Manager was unable to provide a satisfactory explanation in relation to this practice. The Home is required to ensure that satisfactory CRB checks are carried out to Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 17 protect residents from abuse. Registered Nurses working at the Home had their Personal Identification Numbers verified with the Nursing and Midwifery Council (NMC). Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21,22,23,24,25,26 The Home has a generally well maintained and suitable environment, however, it fails to provide sufficient lavatory facilities, general hygiene and cleanliness. EVIDENCE: All bedrooms viewed had adequate facilities, personalised and colour coordinated. Two bedrooms visited were not clean, one of the bedrooms had an offensive smell, another bedroom had ‘feed’ stains on the carpet. Two bathrooms on the ground floor was used for storage with no warning sign. The manager stated that one of the bathrooms is usually cleared if it was to be used. Furthermore, that the baths are not usually done in the mornings due to heavy workload. The Home is required to provide sufficient bathing facilities for the residents. The toilets and bathrooms have grab rails, hoists and other adaptations to meet the needs of current residents. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 19 The Home has a well maintained garden which the residents use in good weather. Residents were noted having a game of Bingo in the shaded area of the garden. The communal areas had comfortable chairs and residents were found to be relaxed in their homely environment. The Laundry had two washing machines and two driers. The washing machines have separate programming facilities. The Laundry staff members stated that all dirty clothes separated are washed individually in a red bag in the washing machine and are not mixed with other clothes. The residents have individual lockers in the laundry where their clothes are kept before being taken to their rooms. All the clothes noted at the Laundry were labelled except new residents whose clothes were distinctly separated awaiting labels from the relatives. The Laundry staff members stated that they have attended COSHH training but have not attended Abuse training. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The Home has a recruitment procedure, however this is not robust and does not offer protection to residents. The number of staff on the early shift is not sufficient to meet the needs of all residents. EVIDENCE: Review of three staff members files examined showed evidence that the Home failed to undertake necessary recruitment checks on two of the staff members to ensure that residents are adequately protected. Criminal Record Bureau checks had not been requested or obtained for one staff member who was employed in February 2005 and one reference was obtained. Another staff member employed in December 2004 had no CRB disclosure. Another staff member had only one reference before commencing employment. On the second day of inspection it was noted that the Home was one staff short between 10am and 2pm. The Manager stated that the staff member rostered to work from 10am – 2pm rang in sick and that she was unable to cover the shift with an agency. The Inspector was given this information about the low staffing level by a visitor to the Home. Staff have attended various training courses to include First Aid, Infection Control, Care of PEG feed, Diabetes and Care of colostomy. The Manager stated that two senior care staff have attended Challenging Behaviour course, these two staff are expected to train the members of staff because the Company have limited resources to train every staff member on this important Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 21 topic. One trained member of staff demonstrated clear knowledge of the needs of the residents on both floors. The trained staff member stated that she/he had attended various training including Duplar Assessment Course, Supra pubic and Male catherization, Dementia and Diabetes courses. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37,38 EVIDENCE: Mrs Jean Davis, the Registered Manager is a qualified nurse. Mrs Davis possesses a Bachelor of Science (BSc) degree in Gerentology and has also attended various courses to include Manual Handling training for trainers and Infection Control, she is currently undertaking Registered Managers Award which is due to complete in July 2005. Mrs Davis also attended a course in Essence of Care. The Manager stated that the Home is currently using the Clinical Benchmarking Tool from the Primary Care Trust as a means of monitoring and improving its care practices and hopes to share ideas with other care homes that are involved with the project. The Manager also stated that the Home is also involved with subcutaneous fluid pilot project. The aim of the project is to admit residents on continuing care to the Nursing Home, provide training for the nursing staff on the treatment required, to avoid Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 23 hospital admissions. Monitoring input of the resident is provided by hospital or PCT. This is commendable and a development opportunity for the registered nurses. The Home currently have no residents on Continuing Care funding Staff spoken with on the day of inspection stated that the Manager is approachable and would listen. One resident stated that the Manager ‘is good’. Another resident stated that he/she would approach the Manager if he/she felt concerned about any aspect of the services provided at the Home. One visitor met on the day of the inspection stated the manager ‘does not talk to relatives’. The Manager needs to be more “sympathetic”. “Staff work hard but need to be led from the top”. “Manager needs to walk around to see the residents”. Some staff members spoken with said they have received supervision, however, two staff interviewed stated that they have not received supervision. This was discussed with the manager who said that she would address these issues. The monthly Provider’s visits reports of the Home are not regularly sent to the Commission. Reports made in accordance with regulation must be sent to CSCI every month. The last report received by the Commission was in March 2005 before this inspection. The monthly reports for the months of April and May were received by the Commission before this report was completed. The home is making efforts in monitoring the quality of it’s services, the manager stated that the home has a Care Home Audit which she completes every month. The document contained all the standards also a care home audit plan. This document was completed in February 2005. The Home is required to implement a quality assurance programme that captures the views of the service users, visitors, relatives and other health professionals. The accident reporting forms were viewed and concerns were raised with the Manager about the number of accidents which have occurred in the home within a short space of time. There was no evidence of reviews to show how injuries sustained were resolved. It was agreed that the Manager would monitor and audit the accident to ensure that residents are protected. Risk assessments were noted in the care files and were regularly reviewed. The fire log book was reviewed and was found to be well maintained. Staff have attended fire safety training, however, there is no satisfactory evidence of the number of staff who had attended fire drills, the last fire drill was on 18th May 2005. The Registered Manager must ensure that staff attend fire drills in order to be aware of procedures to be followed in actual emergency. Bedroom doors were found to be wedged and call bells for several residents were found to be far from the reach of residents. Residents would be at risk if call bells are not within easy reach to summon for assistance. There is a service record of the lift hoists, nurse call system, fire alarm. The Home has policies and procedures in relation to Medication, Abuse, Complaints and Infection Control. Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 24 Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 1 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 x x 2 2 2 Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 26 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. 4. 5. 6. 7. 8. Standard 4 7 38 26 21 38 38 29 Regulation 14 14 16 23 23 23 13 19 Requirement Confirm inwritting that the home is able to meet residents needs. Ensure adequate care plans are in place on how resident needs are being met. Ensure that the home is free fom unpleasant odour Ensure that all parts of the home are kept clean Ensure that bathrooms are not used for storage Ensure that all staff attend fire drills Ensure infection control measures are available at the home Ensure that CRB and two satisfactory references are obtained before staff are employed at the home Ensure that staff are trained on abuse of vulnerable adults. Ensure that staff receive supervision. Ensure that quality assurance system that capures the views of the service users is in place Ensure that the kitchen floor is replaced or repaired Repace or repair a kitchen equipment D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Timescale for action 22/7/05 22/7/05 22/7/05 22/7/05 22/7/05 22/7/05 22/7/05 22/7/05 9. 10. 11. 12. 13. 18 36 33 19 19 18 18 24 23 16 22/705 22/7/05 22/8/05 22/08/05 22/8/05 Page 27 Stanshawes Version 1.30 14. 15. 16. 17. 18. 19. 20. 12 10 38 2 27 37 15 16 18 13 5 18 26 16 21. 38 13 Consult residents in relation to activities Ensure that staff are trained on the impotance of keeping all residents information confidential Ensure that fire doors are not wedged. Provide Terms and Conditions to all residents Ensure that appropriate staffing level is maintained at the home Ensure monthly visits are paid to the home in line with the legislation Provide adequate meals for resident and ensure that fliud intake is provided according to instructions Ensure call bells are within easy reach of residents 22/8/05 22/7/05 22/7/05 22/7/05 22/6/05 22/7/05 22/7/05 22/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Stanshawes D56 D05 S20253 Stanshawes V206185 22-230605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS48 2TH 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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