Inspection on 10/10/06 for Stanton Hall

This inspection was carried out on 10th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stanton Hall 06/09/07

Stanton Hall 15/12/05

Stanton Hall 04/10/05

Stanton Hall 21/03/05

Stanton Hall 27/10/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Stanton Hall Main Street Stanton By Dale Ilkeston Derbyshire DE7 4QH Lead Inspector Steve Smith Unannounced Inspection 10th October 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stanton Hall DS0000002111.V313544.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. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanton Hall Address Main Street Stanton By Dale Ilkeston Derbyshire DE7 4QH 0115 9325387 0115 9442054 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) Excelsior Health Care Limited Teresa Swales Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 40 Places for OP 5 day care places for OP One off variation for SS under 65 years Date of last inspection 15th December 2005 Brief Description of the Service: Stanton Hall is a Grade II listed building set within extensive landscaped gardens. The Home is situated in a small village, which is served by a bus route enabling access to the towns of Ilkeston, Sandiacre, Stapleford and Long Eaton. The Home is registered for the care of 40 older people, and at the time of the inspection residents within the Home were predominately older people with nursing needs. The Home also offers four day care places. There are three lounge areas within the home, and an Edwardian conservatory. The accommodation provided is 20 single bedrooms with en-suite facilities, and 9 double bedrooms without en-suite facilities. There are sufficient toilets and hygiene facilities provided throughout the home. The home is staffed twenty-four hours per day. Full meals are provided each day, personal laundry is attended to, and a programme of leisure and social activities are available. The extensive gardens can be accessed by wheelchair and seating is provided. The charges made for a room at Stanton Hall range from £421.00 to £600.00 a week, dependent on the size of room, the facilities provided, whether the room is a double or single room, and whether residential or nursing care in required`. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 8.5 hours. Discussion was held with Residents, whose records were also ‘case tracked’, and the Manager of the Home. However, the Inspector did not speak to staff. A number of records were examined, and all of the Residents bedrooms and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager was available, and the Commission’s questionnaire sent out to a selection of Residents had been completed by four Residents. What the service does well: What has improved since the last inspection? The Manager had improved the recording of risk assessments on each Resident, and had improved the recording of medication given to all Residents. Training was in place for all members of staff on Safe Guarding Adults. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 6 The Manager has provided quality assurance system within the Home, although some further improvements were still needed. The Manager had improved the moving and handling of Residents, and the recording of accidents in the Home. 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. Stanton Hall DS0000002111.V313544.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 Stanton Hall DS0000002111.V313544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Registered Providers’ statement of purpose and Residents Guide required updating, to ensure that prospective residents would be adequately informed of the operation of the Home prior to deciding to move there. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a statement of purpose for the Home together with a Resident’s Guide. However, the Resident’s Guide had not been updated with a summary of the physical environmental standards met by the Home. In September 2006, the details to be included within the Resident’s Guide where significantly updated by the government, but the Manager had been unaware of this change, and so the Guide was awaiting the necessary updates. The Residents Guide should also have contained information on the Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 9 local Social Services Dept and local Health Authority, but this had not been included. All Residents had been provided with copies of the statement of terms and conditions of residency in the Home or a contract if purchasing their care privately. However, the Manager did not think this included information on the rights and obligations of the Resident and Registered Provider and who would be liable if there were a breach of contract. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager said she completed her own summary of needs, which were seen during the inspection. As a result of these two assessments, Residents’ needs would be appropriately met in the home. Standard 6 does not apply to this Home. Stanton Hall DS0000002111.V313544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Residents’ health and personal care needs were being fully met, as demonstrated within care plans. However, safe medication procedures needed to be updated to ensure that Residents health care needs were always met. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. Files also contained a section recording each Resident’s choice of what furniture etc, was to be provided by the Registered Providers in their bedroom. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were available, and the staff in the Home had completed their own initial assessment of needs for each of the four Residents. There were also Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 11 satisfactory care plans and risk assessments available in each record examined, providing staff with information to met Residents needs. However, the Manager had not ensured that Residents’ possible limitations of choice, freedom and decision-making abilities, if they were suffering from dementia, were formally recorded and reviewed at regular intervals. The files showed that records of events affecting each Resident were kept. However, no record of the formal reviews of care could be found in any of the files, which included reviews carried out by the Derbyshire Social Services Dept or reviews carried out by the Manager of the Home. The Commission recommends that these reviews should be carried out on at least a six monthly basis, and should be signed by each Resident, where they were able. However, where Residents were judged unable to sign their records, the Manager needed to decide with relatives which relative should act as the Resident’s ‘representative’ and to sign the record as such. Residents’ records were easy to read, with regular entries being made. The files were well organised, with different sections, and they were securely stored. However, there was no evidence to show that the Manager reviewed the files on a regular basis, and none of the files contained a confidential section. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined. A good system was found, although one issue needed attention: Paracetamol and Lactulose was found not to be given from each Resident’s supply of medication. The Manager said it was given from one source only, which was inappropriate. Two Residents were spoken to about life in the Home. One said that staff were very good at listening to her views on how she liked to be cared for and staff would carry out her wishes. They both felt very safe in the Home, and appeared to have a strong sense and appearance of well being. Residents were also asked about their wishes following their death at the Home. One said that no one from the Home had discussed this with her, although she had been thinking about this for some time. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 & 15. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Residents preferred lifestyles were respected by staff. Residents were also given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Two of the Residents were asked about the activities provided in the Home. One said that a programme of activities was always provided throughout each week. During the inspection a slide show was provided. These events were organised by two Activity Coordinators. The Manager said that the Activity Coordinators visited the Home Monday to Friday, throughout each day, each week. Residents’ files were seen to show the details of what Residents’ had taken part in, which was maintained by the Activities Coordinators. One of the Residents said that she needed staff assistance to get up and go to bed. Staff were said to be always kind but did not always come at the time preferred by the Resident. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 13 The Residents said that meals were always good - ‘A choice is offered at breakfast, dinner and at tea’. However – ‘If you don’t like what is on the menu, you say so and they will give you something different.’ During the inspection a good variety of meals were observed on the menus and being prepared. During the inspection a staff member was seen assisting a Resident with her dinner, which was done most ably, with appropriate conversation provided by the member staff throughout the meal. One Resident said that she had never been out to the shops, as staff had never offered this opportunity to her. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I can see them in private if I wish.’ However, Residents said that staff do not ‘knock and wait for me to say ‘come in’’ before entering the bedroom. They said that they simply knocked and entered. Residents said that their mail was always delivered unopened, and that the Home was a ‘non-smoking’ home. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 14 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): Standards 16 & 18. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Complaints and concerns made to the Registered Provider or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One of the Residents said that if they had a complaint to make they ‘would tell the Matron’, and it would be investigated. However, she said she had never had to do this. The Commission had not received any notice of complaint since the last inspection of the Home in December 2005. Good procedures and records were maintained of written and verbal complaints. Since the last inspection two verbal complaints had been made, and both were well recorded by the Manager. Both were satisfactorily resolved. The Registered Providers’ complaints procedure also detailed that all complaints would be responded to by a Registered Provider or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. However, this policy had not been made available to staff. There were also copies of the Public Interest Disclosure Act of 1998 and Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 15 the Dept of Health’s policy called ‘No Secrets’ available in the Home. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that a policy was available to staff stating that they could not benefit from Residents wills. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included all of the bedrooms of the Residents. The Home was well decorated throughout, and the lounges and dining rooms were attractive, very pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms provided satisfactory space for each Resident. The extensive grounds and garden were well laid out and looked most welcoming. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 17 However, a number of items needed to be addressed within the Home: 1. The two toilets, opposite to the Manager’s office, had locks that were very difficult to operate, and so would benefit from the provision of new locks. 2. In one of the toilets, again opposite to the Manager’s office, the cupboard below the washbasin was damaged and in need of significant repair. Also in this toilet, the staff call switch was not fixed to the wall, and so when operating the switch it would be pulled onto the floor, rather than summon staff. 3. In the bedroom called Honeysuckle, the washbasin was not of the correct size for a bedroom. It was a hand basin from a toilet and so could not be used to provide a full personal wash. 4. The heating in many bedrooms was to low for a Resident to sit comfortably. Appropriate heating was required in all bedrooms. 5. Door locks were only provided on a few bedroom doors, but should be provided on all bedroom doors. 6. The guttering needed to be cleared of grass growing in it on the side of the building facing the lawns. 7. The Home was still without a sluicing disinfector. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 & 30. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. Nursing and care staffing was not always appropriately provided to meet the needs of Residents. The Manager also needed to ensure that appropriate references were always obtained when employing new members of staff to safeguard Residents welfare. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the four weeks beginning 11 September 2006, the Home was providing care at two levels. During the week beginning 11 September 2006 care was provided at a satisfactory level for 40 Residents. However, during the remaining three weeks care was considered to be unsatisfactory and was provided at a lower level for each of the three weeks examined. As a result the Registered Providers and Manager were asked to review the provision of care for the three weeks commencing 18 September 2006 as the care provided was considered to be to low given the Resident group staying within the Home. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. Across the four weeks reviewed, 12 separate staff were found to have worked at least one double shift, and often more, amounting to 13 hours in one day. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 19 One member of staff was found to have worked 45.5 hours of day shifts and then a further 31.5 hours of night shifts, amounting to 77 hours in total for one weeks work. None of this encourages staff to meet the needs of Residents in a kindly, understanding and patient manner, and is to be strongly discouraged. At the time of this inspection it was found that exactly half of the care staff had a qualification of at least NVQ 2 in Care, which was judged to be a satisfactory level by the Commission. The Manager said that a further 4 staff were currently undertaking the course. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, she had not obtained appropriate references for one member staff. All other records were satisfactory. Staff induction and foundation training was provided for all new staff that came to work in the Home. Records of this training were seen. The Manager also said that all care and nursing staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 & 38. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Registered Providers needed to complete and record their monthly ‘inspection’ of the Home to ensure that Residents needs were being continually met. The Manager needed to address all of the Quality Assurance issues to ensure Residents care was maintained at a positive standard. EVIDENCE: The Manager said that she had completed her training at NVQ level 4, but had not received notification of her pass result at the time of this inspection. It was found that the Registered Providers did not ‘inspect’ the home, or complete a report on that ‘inspection’ for the Manager, on a monthly basis, as required by Regulation 26. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 21 The Manager was able to provide an annual development plan for the Home that reflected the aims and outcomes for Residents. She was also able to show that she had arranged for all Residents to be surveyed, during 2006, and provided the results. She was also confident that her staff would be able to describe the life long learning and development goals for the Home’s Residents. However, she was not able to provide evidence of Residents views on the operation of the Home that had been obtained from individual or group discussion with Residents. She also said that she did not obtain the views of family and friends, of Residents, or of stakeholders in the community, such as GPs, District Nurses and Chiropodists etc on how the Home was achieving goals for its Residents. The Manager was able to show that the personal money of Residents was maintained satisfactorily. However, the savings held for some Residents were considerable, and the Manager was advised to reduce this to a more reasonable amount. The training required by the Regulations was examined. This showed that Moving and Handling training, Fire Safety training, Food Hygiene training and Infection Control training had been provided for all necessary staff. First Aid training had been provided for three care staff, but was still needed by at least 17 further staff. In addition to the above required training, the Manager said that training was also provided for NVQ level 2 and 3, Health and Safety training, Care Practice training and Palliative Care training for all care staff. In addition, Nurses were provided with further training in Dysphasia, Nutrition, P.E.G. Feeding regimes, Tissue Viability, Continence and Supervision Care training. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that she had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff, and had provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices in the Home. The Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She was also able to show, that with the assistance of the Fire Service, fire safety notices were posted in relevant places around the Home. Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Registered Providers and Manager need to review the Residents Guide and update it in line with the legal changes that came into force in September 2006. The Registered Providers must provide in the statement of terms and conditions of residency, or contract, information on the rights and obligations of the Resident and Registered Provider and who is liable if there is a breach of contract. All medications must be given to each Resident from the Resident’s own supply of medication provided by the pharmacy. Heating in bedrooms must always be provided at an appropriate level to allow Residents to return to their bedrooms at anytime during the day. Timescale for action 31/01/07 2. OP2 5 31/01/07 3. OP9 13 04/12/06 4. OP25 23 04/12/06 Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 24 5. OP29 19 The Registered Providers and Manager must check, and hold documentary evidence, that all new staff employed have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, amended in 2004. The Registered Providers must complete a monthly ‘inspection’ of the Home, together with the necessary paperwork, to satisfy Regulation 26. Training in First Aid must be provided for the Care staff identified during the inspection. 04/12/06 6. OP31 26 04/12/06 7. OP38 13 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Registered Providers should provide a summary of the environmental standards, detailed in Standard 1.1, and include this in the statement of purpose, and in the Resident’s Guide to the Home. The Residents Guide should contain information for Residents on the local Social Services Dept and local Health Authority. 2. OP7 The Registered Providers need to ensure that each Resident suffering with dementia, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. The Manager needs to complete formal 6 monthly reviews Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 25 of care with Residents. Those attending the review should include the Resident, their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. The Manager should carry out monthly quality checks of all Residents files. All Residents files should also contain a ‘confidential’ section. 3. OP11 All Residents should be provided with an opportunity to plan their funeral arrangements shortly after moving to the Home. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. The Registered Providers and Manager should ensure that staff are given copies of the Whistle Blowing policy on appointment to the Home. Provide more appropriate locks on the two toilet doors opposite to the Manager’s office. In one of the above toilets the cupboard below the washbasin needs urgent repair. Also in this toilet the staff call switch needs to be fixed to the wall. The washbasin in the bedroom called Honeysuckle should be replaced with one of an appropriate size for a bedroom. The one currently provided is a hand basin from a toilet. The guttering needs to be cleared of grass growing in it on the side of the building facing the lawns. 7. OP24 All bedroom doors should be fitted with a lock that can be operated from both the inside and outside of the room by the Resident. Each Resident should be provided with a key to their bedroom. Risk assessments should be carried out, and recorded in the Resident’s file, when it is considered by the Registered Providers that the Resident is not able to hold the key to their bedroom. DS0000002111.V313544.R01.S.doc Version 5.2 Page 26 4. OP12 5. OP18 6. OP19 Stanton Hall All care staff and cleaning staff should be provided with masterkeys to Residents bedrooms. 8. 9. OP26 OP27 At least one sluicing disinfector should be provided. The nursing and care staffing levels provided within the Home should always be at least equal to that recommended by the Residential Forum. The Registered Providers and Manager should review the length of time nursing and care staff are allowed to work in the Home, and where possible limit this to no more than one shift per day, of approximately 8 hours, and 40 hours each week. 10. 11. OP31 OP33 The Manager needs to obtain a qualification in Management at NVQ level 4 by 31 December 2006. The Manager should ensure that she is satisfying all of the Quality Assurance items listed in Regulation 33, particularly Regulation 33.6 and 33.7. The Manager should limit Residents saving to the amount recommended during the inspection. 12. OP35 Stanton Hall DS0000002111.V313544.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stanton Hall DS0000002111.V313544.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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