Inspection on 04/10/05 for Stanton Hall

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stanton Hall 06/09/07

Stanton Hall 10/10/06

Stanton Hall 15/12/05

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 4th October 2005 09:30 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.V255851.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.V255851.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.V255851.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 21st March 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.V255851.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 six 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 manager. The inspector spent a considerable amount of the inspection concentrating on case tracking, needs assessments, care plans and the care arrangements for Service Users, and the homes ability to meet the assessed needs of the residents. 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? The home has a rolling programme in place for the refurbishment of the home and an application is in place to extend the home in the near future demonstrating that financial reinvestment in the home is occurring. The home continues to strive for improvement in all aspects of care provided to the residents. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 6 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.V255851.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.V255851.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): 1.2.3.4.5. The admission and assessment process was clear and accessible EVIDENCE: The home has a Statement of Purpose in place. Four residents files were examined for the purpose of case tracking, all four had full needs assessments carried out prior to being offered a place at the home. The matron/deputy carry out all the needs assessments, except where a Care manager is involved and they supply all the relevant information. A Terms and Conditions document is now provided to all potential residents, it is also included in the residents’ information guide. Trial periods are offered to potential residents’. Residents’ files examined for the purpose of case tracking were well structured and the information held was easily accessed. Intermediate services are not offered at this home. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 9 Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 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): 7.8.10. The individual care plans are generally informative however there were some inconsistencies in the recording of information. EVIDENCE: The four case files examined all had individual care plans in place for each resident, the care plans were detailed and informative, however it was noted that there were inconsistencies in the quality of the recording. One file was found to be completed as required and the relevant information was available. The other three files examined had incomplete risk assessment for nutritional screening; the use of bedrails and the constipation records were not completed. There were a number of documents that had not been sign and dated as required. The files would benefit from being organised in such a way as to enable easy access to information; information on one area of care was kept in different parts of the file. A range of health services is available to all residents, which includes access to dental care, hearing and eye sight tests, chiropody both National Health Service and private and each resident has their own general practitioner. Residents spoken to stated that they felt staff did treat them with respect at all times. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 11 The home has a privacy and dignity policy in place. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 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): 12.13.15. Relatives and friends can visit at any reasonable time; residents are encouraged to take part when able in leisure activities, and social events both inside and outside the home. The food provided is varied and well presented. EVIDENCE: The Home provides a dedicated activity worker, resident spoken to said that they were very happy with the activities provided one resident talked about a recent canal boat trip from the home and she said “ it was marvellous and we had fish and chips more than I could eat but it was lovely” Another resident said “we go to the local pub sometimes and we enjoy that” The home has an activities programme in place. Links with the local community are maintained through visitors and trips out, the home has an ‘open door’ policy in place and the residents spoken to stated that they had regular visitors and that staff always made them feel welcome. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 13 The lunch period was observed and found to be both calm and relaxing; the dining area was well presented. Staff were observed assisting residents in a caring and sensitive manner. The food provided was both varied and nutritionally well balanced, the food provided was according to the menu and an alternative was offered. One resident who is diabetic spoke of having no choice of puddings, this was checked out with the cook and the manager at the time of the inspection, they were able to demonstrate that there was in fact four different puddings available for people who are diabetic. Residents spoken to stated that the food was very good and that they enjoyed their meals, no complaints were expressed. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 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): These Standards were not assessed during this inspection. EVIDENCE: Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26. The home is generally well maintained internally and externally, however the home is at present in the process of refurbishment and an application for an extension is being sought. EVIDENCE: A number of residents’ rooms were assessed and found to contain the required furniture as identified in Standard 24. The rooms assessed had been personalised. One resident spoken to for the purpose of case tracking said “I I’m not bothered about sharing my room but I really don’t like it” this was discussed with the manager who agreed to look at a room change when a vacancy occurs. There are sufficient toilets and bathrooms provided to meet requirements, however the upstairs bathroom is in need of complete refurbishment, the provider said that it was going to be replaced as part of the refurbishment programme. The communal areas are light warm and clean, comfortable easy chairs are provided and the furnishing in general is homely, wheelchair access to the gardens is provided. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 16 The home has started to fit locks to the residents’ doors and provide lockable storage this is now ongoing as doors are decorated locks will be fitted. The home has not fitted a sluice disinfector as required. This is an outstanding requirement from the inspection dated 21/03/05 No offensive odours were noted and the home was generally well maintained. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 17 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): These Standards were not assessed fully during this inspection. Staff rotas were examined and staffing levels were found to be satisfactory. It was noted that the home is experiencing some difficulty in recruiting staff when vacancies occur. EVIDENCE: Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 18 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): 33.35.36.37. The manager has started to develop a Quality Assurance system. There is a system for recording residents’ financial transaction in place. EVIDENCE: Questionnaires have been developed and given to residents and relatives/carers information had been gathered but at the time of the inspection the information had not been evaluated and put into a public document. Residents’ financial transition records were examined and found to meet requirements. A random sample of staff files were examined and there were completed supervision records and completed induction programmes in place. A number of the homes records were examined including staff rotas, resident care plans and needs assessments, staff documents as part of the recruitment process all the documents assessed were satisfactory. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 19 The Terms and Condition of residency document had been amended to reflect Regulation 5A(The Care Homes Amendment No2) Regulation2003. Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 3 3 x Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP7 Regulation 23(2)(b) 13(4)(a) 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 terms and conditions must be amended to reflect Regulation 5A (The Care Homes (Amendment No. 2) Regulations 2003) Outstanding requirement in two previous inspection reports dated October 2003 and October 2004. Timescale for action 01/03/06 01/01/06 3 OP24 16(2)(c) 01/03/06 4 5 6 OP26 OP33 OP2 23(2)(k) 24(1) 5A(1)(2) 01/03/06 01/03/06 01/01/06 Stanton Hall DS0000002111.V255851.R01.S.doc Version 5.0 Page 22 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.V255851.R01.S.doc Version 5.0 Page 23 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. 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