Inspection on 15/12/05 for Stanton Hall

This inspection was carried out on 15th December 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 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 10/10/06

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 Gail Meads Unannounced Inspection 09:45 15 December 2005 th 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.V273914.R01.S.doc Version 5.0 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.V273914.R01.S.doc Version 5.0 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.V273914.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 40 Places for OP 5 day care places for OP One off variaiton for SS under 65 years Date of last inspection 4th October 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 town of Ilkeston. The home is registered for the care of 40 older people, 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. The gardens can be accessed by wheelchair and seating is provided. There are three lounge areas within the home, including 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 toilet and hygiene facilities provided throughout the home. The home is staffed twenty-four hours per day a range of health services are available, 3 meals per day, personal laundry and a programme of leisure and social activities are available. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a 4 and a half hour period time was also spent in preparation for the visit, looking at previous reports and other documents. During the inspection apart from examining the home’s documents and records, time was spent looking around the building and speaking to residents and to the nurse in charge and the proprietors’ son. Staff were observed throughout the visit, responding to the needs of residents and visitors in a sensitive and friendly manner. What the service does well: What has improved since the last inspection? What they could do better: Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 6 The organisation and recording of information as to the disposal of unused medication must be in place and up to date. Staff information was unavailable for inspection, the proprietor maintains this is a of data protection issue. The proprietor must look at developing a system that ensures all documents that are inspected are available at all times. All members of staff must practice safe moving and handling. All accidents must be recorded and show the action taken by staff. 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.V273914.R01.S.doc Version 5.0 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.V273914.R01.S.doc Version 5.0 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): These Standards were not assessed during this inspection as they were assessed in the last inspection dated the 04/10/05 and were found to be satisfactory. EVIDENCE: Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9.10. Medication is administered and recorded as required. The care of residents who are dying is sensitive and caring. EVIDENCE: The administration of medication was observed during the lunch period, all medication was given/taken to residents and the nurse observed the resident take the medication. Medication was recorded as administered. The receipt of medication was recorded on the residents MAR sheet as required. The disposal of medication had changed and the nurse in charge stated that boots no longer provided this service and they had now contracted out to a private company. The nurse and the proprietors’ son were unable to provide an up to date record of the disposal of drugs. The senior nurse stated that when a resident is dying the general practitioner is involved the care needs are identified and the home will try to meet the needs of the resident. Macmillan nurses are requested if needed. The family are involved and can visit at any time. The spiritual needs of the resident are respected and the appropriate people are requested to visit. The resident is never left alone staff will sit with them when relatives are not visiting. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 10 Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents are encouraged to be as independent as possible when appropriate. EVIDENCE: Residents are offered the opportunity to deal with their own finances and also self medicate when appropriate and the resident has the ability and capability to do this safely. Residents are encouraged to retain their right to vote. Disclaimer forms are signed by residents to identify if they wish to handle their own affairs or give the responsibility to staff within the home. At the time of the inspection there were no residents self medicating or handling their own financial affairs. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 12 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): Complaints are generally responded to promptly and appropriately. EVIDENCE: There had been five complaints since the last inspection all had been dealt with promptly however there were two complaints from the same person who had complained that her relatives bedroom was untidy and dirty and it was noted that there was a third complaint of the same nature. The complaints had been recorded as required and showed a clear process of addressing the complaint according to the homes own complaints policy. Residents who need legal advice are offered the opportunity of having an advocate from Age Concern. The senior nurse stated that a solicitor would be sought if needed. The majority of staff have now received Adult Protection training only six staff had not attended a course and this was to be organised for early next year. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 13 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): These Standards were not assessed during this inspection as they were assessed in the last inspection dated the 04/10/05 and were found to be satisfactory. EVIDENCE: However it needs to be noted that there have been some improvements made to the environment since the last inspection theses are as follows: • The downstairs toilet and shower room have been refurbished. • Bedrooms are being refurbished as and when they become vacant room Garden suite four had been refurbished to a good standard. • Decoration is ongoing. There is a temperature difference noticeable between the conservatory and the front entrance. No call system was in place in the refurbished shower room and toilet. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 14 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): Unable to assess staff details as unavailable for inspection. EVIDENCE: Matron off duty and she has the only key to staff files. Spoke to proprietor and pointed out the need to have access to all documents for inspection but proprietor stated. he would not change the system one because that was the way the matron wanted it and two under data protection he felt they should not be accessed by other staff even senior staff. Residents spoken to about the level of care given by staff spoke quite positively although there was one resident who asked if there were any carers around as she needed some assistance with her bedroom curtains and she said “I have not seen any recently” the proprietors son helped her with the curtains. Another resident spoke at some length about an injury she had received when a member of staff had apparently tried to help her to get up and not used the correct moving and handling procedure, this was checked with the senior nurse who was unable to provide clear information about this incident there did not appear to be an accident form completed although there were records which evidenced that the wound had been dressed regularly. Another resident with grazes above her eye and on her cheekbone when asked how it occurred said “I fell in my bedroom at about 7am” when asked what staff had done to help she said “nothing their not bothered” this was also checked with the nurse in charge and the proprietors son both of whom could not provide an accident record of the accident. It was also noted that when looking at the accident record an accident had been recorded five days after the accident occurred. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 15 Other residents stated that they like the home and that staff were very kind and caring. One relative spoken to stated that they could not do enough for the residents and were always helpful. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.34.37.38. The manager was not on duty however during the last inspection the manager was found to be approachable and competent in her management of the home. Some records for inspection were unavailable. Record keeping would benefit from being more organised to enable information to be easily accessed. EVIDENCE: Residents spoken to stated that they found the matron friendly and approachable. As previously mention in Standards 27-30 accident records were not available for inspection and it appeared that some accidents had not been recorded as required. A doorstop was being used in the room next to the office. Records maintained for the disposal of medication could not been found for inspection. Staff supervision records were not available for inspection. Accidents had not been recorded as required. Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 17 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x 2 2 Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 18 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. Standard 1. OP19 Regulation 23(2)(b) Requirement The registered person must ensure that the upstairs bathroom is refurbished. The registered person must ensure that risk assessments are fully completed, signed and dated. Bedrooms must have locks on doors, comfortable seating for two and lockable storage space. Reasons not to provide these items must be recorded. A sluicing disinfector must be provided An effective quality assurance and quality monitoring system must be put in place The registered person must ensure that the disposal of medication is clearly recorded and available for inspection. The registered person must ensure that all members of staff are using a safe system for the DS0000002111.V273914.R01.S.doc Timescale for action 01/03/06 2. OP7 13(4)(a) 01/01/06 3. OP24 16(2)(c) 01/03/06 4. 5. OP26 OP33 23(2)(k) 24(1) 01/03/06 01/03/06 6 OP9 13(2) 01/01/06 7 OP38 13(5) 01/01/06 Stanton Hall Version 5.0 Page 19 8 OP38 9 OP38 10 11 OP36 OP37 12 P27 13 OP38 14 OP18 moving and handling of residents at all times. 23(4)(c)(i) The registered person must ensure that doorstops are not used to keep open residents bedroom doors. 17 Schedule The registered person must 3(3)(j) ensure that accidents are recorded at the time of the accident. All accidents must be recorded as required. 18(2) The registered person must ensure that supervision records are available for inspection. 17 Schedule The registered person must 3 and 4 ensure that the records identified in Schedule 3 and 4 are maintained as required. 17(3)(b) The registered person must ensure that all documents maintained from Standard 27 – 30 are available for inspection at all times. 13(4)(c) The registered person ensures that all risks to the health and safety of residents are identified and action taken to eliminate the risk. This includes the provision of a call system in the refurbished shower room and toilet. 18(1)(c)(i) The registered person must ensure that all members of staff receive Adult Protection training. 01/01/06 01/01/06 01/01/06 01/01/06 01/02/06 01/01/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 20 Stanton Hall DS0000002111.V273914.R01.S.doc Version 5.0 Page 21 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.V273914.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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