Inspection on 06/09/07 for Stanton Hall

This inspection was carried out on 6th September 2007.

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 10/10/06

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 Angela Kennedy Key Unannounced Inspection 6th September 2007 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.V341480.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.V341480.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 stantonhall2006@aol.com 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.V341480.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 variaiton for SS under 65 years Date of last inspection 10th October 2006 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 fees for a room at Stanton Hall ranged from £436.00 to £624.00 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 is required. Trips out were funded through the homes amenities fund, however personal monies were required for items purchased on these trips. Other items not included in the weekly fee included: Alcoholic beverages, hairdressers services, private chiropody and newspapers / magazines. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 5 Further information regarding the service and accommodation provided at Stanton Hall are available within the homes service user guide and brochure. These can be obtained by contacting the registered manager at Stanton Hall. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced and took place over five hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment and the information provided within this assessment has also been used within this inspection report. The registered manager was present at the inspection. Staff opinions were also sought to ascertain their views of the service and their opinion of the training and support provided to them. Three residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the resident if they are able to communicate or observing the care they receive. Several other residents were also spoken with at this inspection visit and one visitor, to gain their views on the services and care provided at a Stanton Hall. What the service does well: What has improved since the last inspection? Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 7 Of the requirements made at the last inspection visit the majority of these have been met. This included; The home service user guide that has now been updated in line with the government’s changes that came into force in September 06. Updating resident’s terms and conditions/ contracts to include information on the rights and obligations of the resident and registered provider. A care plan is now in place that addressed limitations of choice, freedom and the decision-making abilities of the individual. This care plan documented the mental health condition of the individual, such as dementia and stated the named representative for that individual regarding decisions, such as their next of kin. This care plan also confirmed that all decisions must be made in the best interests of the individual and documented in their care plan, stating the reason why the decision was made and the outcome of the decision made. All medication held was from the residents own supply provided by the pharmacy. Monthly provider visits were undertaken and the reports were in place to demonstrate this. What they could do better: Residents who chose to self-administer their medication had disclaimers in place to demonstrate their agreement to do so and their agreement to store their medication safely. However no written risk assessment had been undertaken regarding the individual’s ability to carry out this agreement. Once risk assessements are in place this will further demonstrate that residents safety is enhanced. Although a good complaints procedure was in place there was no system in place for recording minor concerns and the actions and outcomes that were taken by the service. Once records are maintained this will further demonstrate that the home takes all concerns seriously and acts promptly to resolve them. A full employment history with the reasons for any gaps in employment must be recorded on employment application forms. This should include the applicants reasons for leaving any positions were the applicant worked with vulnerable adults and/ or children. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 9 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.V341480.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents had the information they needed to make an informed choice about the service, and terms and conditions of residency provided information on the rights and obligations of the resident and the provider. Resident’s needs were assessed prior to moving into Stanton Hall EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: Prospective residents and / or their families are shown around the home and informed of the services available. A detailed brochure, including photographs, is provided along with a guide to choosing a nursing home and a copy of the homes terms and conditions. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 11 Residents are invited to have a trial visit if they wish to do so. This ensures that they are able to make an informed choice about where to live. Prior to admission detailed pre-admission assessments are carried out and documented by qualified nursing staff to assure that the needs of the resident can be met by the home. Residents and their representatives are given time to discuss their needs and expectations with staff prior to admission in order to ensure a smooth transition process. The information gathered is then used in the compilation of the resident’s plan of care. Qualified staff receive training in dealing with enquiries, pre-admission assessments and care plan formulation. On the day of the inspection visit: The Resident’s Guide was looked at and met with the government’s updated requirements set in September 2006. The additional information now contained in The Resident’s Guide included, a summary of the physical environmental standards met by the Home and information on the local Social Services Dept and local Health Authority. 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. This now 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. The pre admission assessments of the three residents case tracked were looked at. All had assessments in place that had been undertaken prior to admission. These assessments addressed all areas of personal, health and social care needs. For residents that were funded an assessment of needs was also undertaken by the funding authority prior to admission. This was confirmed within one of the resident’s files looked at, whose care was funded by the local authority. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health,personal and social care needs and how they are to be met are set out in their plan of care, with resident involvement . The homes medication practices in general protect residents but require further detail to demonstrate that residents safety is enhanced. Residents were treated respectfully and their right to privacy maintained. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: Each client has a detailed individual plan of care using information gathered prior to and on admission. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 13 Residents and their representative are given the opportunity to be involved in the care planning process, giving them input into the care provided. Care plans are reviewed monthly or more frequently if the resident is unstable, so that the current needs of each resident are accurately reflected. A variety of external professionals are involved in the care of the residents, ensuring that their needs are appropriately met. Specialised equipment is available for all residents, to make their lives as comfortable as possible. Several assessments are carried out so that the health and safety of the residents, and the staff, is protected within the risk management framework. Medications are managed within the current guidelines. Residents who wish to self medicate are assessed by their own GP and lockable storage facilities are available in the residents bedroom in which to store the medication. Medications are received, stored and disposed of within current guidelines. All residents are treated with respect and their rights to privacy upheld . On the day of the inspection visit: Risk assessments were in place in all three of the residents files seen. These risk assessments were detailed and provided good instruction to the staff team on the support required to ensure each individuals needs could be met. The risk assessment in place included a general risk assessment that addressed age, invasive procedures, body fluid exposure, mobility, immunity and communication. In addition to this, assessment were also in place that looked at risk of falls, nutrition, skin integrity, moving and handling and assessment specific to each individual. From the risk assessments in place care plans had been formulated. These care plans covered all areas of social, personal and health care needs. Included within the care plans seen was a mental health care plan that addressed limitations of choice, freedom and the decision-making abilities of the individual. This care plan documented the mental health condition of the individual, such as dementia and stated the named representative for that individual regarding decisions, such as their next of kin. This care plan also confirmed that all decisions must be made in the best interests of the individual and documented in their care plan, stating the reason why the decision was made and the outcome of the decision made. Evidence was in place that demonstrated that health care needs were addressed promptly and this included referrals to the relevant health care professionals. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 14 Written records were maintained of all health care professionals visits and included the outcome of each visit and any further action required. On initial assessment of each individual there was a declaration regarding each individual’s wishes/ abilities to be involved in the formulation of their care plans. One of the three residents whose records were seen had signed to say they wished to be involved in the formulation of their care plans. The other two residents had indicated that they did not wish to be involved. However within this declaration there was a paragraph that stated that those individuals not wishing to be involved in the formulation of their care plans would be verbally update regarding their care plans and any changes made. None of the files seen contained a confidential section; this was a recommendation that was made at the last inspection visit. Discussions with the manager confirmed that this had not as yet been put into place. Care plans were reviewed by the individual’s named nurse each month. However it was noted that some care plans seen had not been reviewed since July 07. The manager stated that this was due to staff holidays. However it is important that all residents care plans are reviewed each month to ensure any changing needs are identified and a proactive approach to care is maintained. Discussions took place with the manager regarding another recommendation that was made at the last inspection visit. This was in relation to the manager reviewing care plans on a regular basis. The manager stated that she would be unable to physically review the care plans of every resident each month, as this would be too time consuming. It was therefore suggested that this could be done by the Senior Sister’s when undertaking staff supervision sessions. Discussions regarding six monthly formal reviews of each person’s plan of care took place with the manager. It was confirmed that this had not been undertaken, although the manager did state that any concerns or issues regarding any individual’s care was addressed as and when any concerns were identified. Residents spoken with were complimentary about the care provided to them by the staff team and comments included “ the staff are lovely, they’re very kind” and “ the staff are very good, they look after us” and “ the staff are lovely and they’re always very busy so they don’t often get chance to sit and chat”. The medication practices at Stanton Hall were looked at. Administration records had been signed appropriately by staff and all medication was stored appropriately and accurate records maintained. At the last inspection visit it was observed that medication such as paracetamol and lactulose were administered from one source rather than from each individuals own supply. This has now been amended and evidence Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 15 was in place to demonstrate that individuals now had their own prescribed supply of this medication. Residents who chose to self-administer their medication had disclaimers in place to demonstrate their agreement to do so and their agreement to store their medication safely. However no written risk assessment had been undertaken regarding the individual’s ability to carry out this agreement. Discussions took place with the manager regarding residents who chose to self-administer their medication and the need for each person to have a written risk assessment in place. This was to demonstrate that they had been assessed as having the capacity to store and administer their medication safely and as prescribed. Residents spoken to confirmed that staff behaved respectfully towards them and this included knocking and waiting for a reply before entering their private accommodation. Observations of staff with residents on the day of this inspection visit also demonstrated a courteous and respectful attitude was afforded to residents. Discussions took place with the manager regarding residents having an opportunity to plan for their funerals shortly after moving into the home. As this was a recommendation from the last inspection visit. The manager felt that this was not always appropriate as some residents were anxious regarding moving into a care home and may become distressed if funeral arrangements were discussed with them. The manager confirmed that she had written to all residents or their representatives regarding their wishes after death but stated that to date she had received few responses. Evidence of letters sent out and any responses were held within resident’s personal files. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The range of activities that has been provided needs to be maintained to ensure residents needs continue to be met. Relatives were made welcome so that important contact for residents was maintained. There was a varied menu provided so that residents enjoyed their meals. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: We have a wide and varied social activities programme. Records of outings and activities are kept in the residents files. We have purchased a mini bus for outings. Residents are given an array of menu choices at all meal times and staff are always available to assist with meals if required.Residents are encouraged to sit at the dining table at meal times for the social aspect of this. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 17 Residents have visitors when they wish and can go out if they choose and it is safe for them to do so. They are able to go to their rooms if they wish when they do have visitors. Residents are given the opportunity to exercise choice and control over their lives. We have excellent relationships with the local churches and ministers from various faiths to ensure that residents spiritual needs are met as far as practicably possible. Personal mail is always given to the resident or their named representative unless otherwise requested - this is then documented in the care plan. Residents have access to PALS (patient advice and liaison service) and Age Concern to advocate on their behalf. On the day of the inspection visit: Discussions with the manager regarding the activities for residents’ at Stanton Hall confirmed that at the time of the inspection the activities for residents had been limited due to the activities co-ordinator leaving. The manager confirmed that the post of activities co-ordinator had been advertised, and on the day of this visit several enquiries were made to the home regarding this post. The activities assistant remained in post and was able to provide some activities for the resident group. Residents spoken with stated that the activities and outings that had been provided were very good and included trips out, such as boat trip on the river Trent and lunches out. A physiotherapist visited the residents at Stanton Hall once a week and provided group and one to one exercises for residents. This was confirmed by one of the residents who stated that the physiotherapist had worked with them the previous day. Indoor activities that were available to residents included a variety of board games, quizzes, reminiscence sessions and external entertainers such as singers. The manager confirmed that other entertainment provided recently included a ‘Chinese day’ and a clothes show. It was also stated that residents were able to go out on a one to one basis with staff to the local shops. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 18 Aromatherapy was provided once a week as was the services of a mobile hairdresser. Residents spoken with confirmed their friends and relatives were able to visit at any time. One relative spoken with stated that they visited their mother every day and were always made welcome by the staff team. Residents were able to bring some of their personal possessions with them on admission to the home and this was discussed with one resident who had recently moved into Stanton Hall. This resident confirmed that they had brought some of their belongings from home with them, which had helped to personalise their room, this included their own television, shelving, ornaments and photographs. From the menus seen and from discussions with residents it was established that two choices were available at the lunchtime and teatime meal for both main courses and desserts. It was also noted that a starter of ‘soup of the day’ was also available at the lunchtime meal. All of the residents spoken with confirmed that the meals provided were of a good quality and enjoyed. Comments from residents included, “the meals are very nice and you don’t have to sit at the dining table if you don’t want to, I prefer to sit at my chair with a table in front” and “ the food here is very good, there’s plenty to eat and plenty of variety”. A visitor of one of the residents also commented on the meals provided saying, “the meals seem very good, mum always enjoys her food”. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives were confident that any concerns they had would be addressed promptly. Stanton Hall has satisfactory safeguarding adults systems in place, including a whistle-blowing policy to support staff. The systems safeguard residents living at the home. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: The Complaints policies and procedures are available to residents, representatives and staff and clearly states the appropriate procedure to be followed in the event of a complaint. The procedure is available on notice boards at various points around the home, in the brochure (service user guide) and in the Statement of Purpose. Any complaints received are addressed to meet the resident’s needs. The protection policies and procedures in place mean that the residents are well protected. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 20 There is a Whistleblowing Policy in place and all staff are made aware of it at induction and again through recognising abuse training. The Safeguarding Adults procedure also includes copies of the Public Interest Disclosure Act and the subsequent Date Protection Policy, and there is a copy of the DOH No Secrets available. Staff attend annual training and updates in Recognising and Alerting Others to Abuse, and feed back from this is very positive. The training has been delivered to domicillary staff as well as care staff, which has led to improved communication and understanding between the teams. On the day of the inspection visit: The complaints procedure was clear and included the 28-day timescale for response to complaints. The contact details for the commission for social care inspection were also included. No formal complaints had been received at Stanton Hall since the last inspection visit. The manager discussed minor concerns that had been raised by residents or their representatives, such as items of lost clothing but these had not been recorded as complaints. It was agreed that minor concerns and their outcomes should be recorded on a separate ‘concerns’ sheet such as within resident’s personal files. This would clearly demonstrate that all concerns raised are acted upon. Not all of the residents spoken with were sure if they had seen the complaints procedure at Stanton Hall but confirmed that if they had any concerns they would speak with the registered manager. One visitor spoken with said that if she had any concerns she would speak with a member of staff, this visitor confirmed that in the past any concerns she has had have always been dealt with promptly and to her satisfaction. This visitor confirmed she was aware of the complaints procedure. Following the last inspection visit information was brought to the attention of the Commission regarding the employment of a member of staff at Stanton Hall. This information was passed to the Registered Manager who promptly investigated the concerns raised and provided satisfactory feedback to the Commission of the actions that had been taken. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. This policy has now been made available to all staff and is provided as part of the induction pack given to staff at the start of employment. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 21 In place at Stanton Hall was a copy of the local authorities policy on Safeguarding Adults. The registered manager confirmed that she had undertaken the local authorities trainers course to enable her to provide safeguarding adults training to the staff at Stanton Hall. The majority of the staff team had undertaken safeguarding adults training. The manager confirmed that staff recently employed or awaiting a start date would be undertaking this training within the near future. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Stanton Hall is furnished, cleaned and maintained to a good standard, providing residents with a safe, pleasant and comfortable place to live. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: The home is well maintained through a continuous refurbishment programme.Annual risk assessments of the environment are carried out and acted upon if necessary. The bedrooms provide satisfactory personal space for each resident - some of the rooms are large and can be laid out as bedsitting rooms if required. Residents are actively encouraged to bring in their own belongings and personal items if they wish to do so. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 23 Rooms are comfortable and warm. Supplementary heating is readily available if required by the resident. . Door locks are fitted for residents who require them. If door locks are not required by the resident or their representative it is documented and signed in the residents careplan. The home is clean and odour free. There are strict infection control policies and procedures in place and staff receive regular training in infection control. The home has provided a variety specialist equipment in order for the residents to maximise their independence. The grounds are extensive and well laid out. There is disabled access to the grounds to enable all residents to make use of them The gardens are maintained regularly and we have wheelchair access and suitable furniture for the residents use. On the day of the inspection visit: A partial tour of the building was undertaken. The sitting rooms and dining rooms were spacious and comfortably furnished. The residents spoken with were satisfied with their private accommodation and had been encouraged to personalise their rooms. At the last inspection visit the heating in many bedrooms was to low for a resident to sit comfortably and a requirement was made that appropriate heating be provided in all bedrooms. As stated above the registered manager confirmed that supplementary heating was available for any residents that required it. At the time of this inspection the weather was warm and therefore all rooms within the home were found to be of a satisfactory temperature. At the last inspection visit it was observed that door locks were only provided on a few bedroom doors, rather than on all bedroom doors. This continues to be the case although it was noted in the resident’s personal files seen, that disclaimers were in place that had been signed by residents or their representatives to indicate if they required a lock and key to their bedrooms. Of the personal files seen one resident had indicated and signed to say that they required a lock and key to their bedroom. This person was spoken with and confirmed that they had a lock and key to their room. At the last inspection visit the two toilets, opposite to the Manager’s office, had locks that were very difficult to operate. New locks have now been fitted to these doors. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 24 At the last inspection visit 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. This cupboard was seen and it was agreed by the manager that it needed repainting to enhance its appearance. 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. This call switch has now been fixed to the wall. At the last inspection visit in the bedroom named 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. No changes have as yet been made to this. The home was very clean and tidy at inspection and residents confirmed that the cleaning and hygiene standards are good. Residents said that there was an efficient and prompt laundry service at the home. At the time of this inspection the laundry facilities had been relocated to a mobile unit within the grounds. This was to allow building work to be undertaken. The mobile unit housed two washing machines and two tumble driers. However neither of the washing machines in place provided a built in sluicing facility. The manager confirmed that a washing machine with a built in sluicing facility was on site but was at present in storage until the laundry facilities were relocated following the completion of the present building work. At the last inspection visit it was confirmed that the Home was still without a sluicing disinfector. This continues to remain the case. The extensive grounds and garden are were well laid out, safe and accessible to the residents At the last inspection it was observed that the guttering on the side of the building facing the lawns had grass growing in it. This was not looked at during this inspection visit, but the manger confirmed that the grass had been cleared from this guttering. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The numbers of trained staff on duty are sufficient to meet the needs of the resident group. The recruitment procedures require further development to ensure residents are safeguarded. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: Staffing rotas.(The original copy and working copy are both kept) Staffing levels are worked out according to the Residential staffing forum based on 32 residents. (Although we are registered for 40 beds for the past year we have only accepted a maximum of 32 residents in order to carry out our refurbishment programme and increase the number of single rooms). Extra staff are brought in at peak times of activity i.e. we have someone specifically for serving breakfast and assisting residents who need help to eat. The majority of care staff have now NVQ 2. Several staff have started Level 3. Staff are encouraged to achieve NVQs and attend study days and training. Residents are supported and protected by the homes recruitment policy and procedures. Two references and a CRB check are obtained for all staff Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 26 members, including volunteers. Records of these are kept in the individual personal profiles. Staff have a training and development programme to ensure that they are competent to do their jobs. Staff training records and certificates are kept in individual personal profiles. Training needs other than those which are mandatory are identified through supervision and appraisal. On the day of the inspection visit: Thirty residents were living at Stanton Hall and one resident was staying at Stanton Hall for respite. Excluding the manager’s hours, the numbers of care staff on duty were five care staff in the morning with two qualified nurses and five care staff in the afternoon with one qualified nurse. One qualified nurse and two care staff were on duty at night. The assistant activities coordinator worked Monday to Friday from 7.30am to 1.30pm. Apart from coordinating activities the role of this member of staff also included assisting those residents who required support eating their breakfast and lunch. In relation to the numbers and dependency levels of the residents, the staffing levels in place at the time of this inspection met those recommended by the Residential Forum. At the last inspection visit it was noted that some members of the staff team were working in excess of twelve to thirteen hours a day. Discussions took place with the manager regarding this and it was confirmed that although staff continue to cover some shifts over their contracted hours these hours are monitored to ensure they are not excessive and allow for sufficient rest breaks. Discussions with some members of the staff team took place. In general the staff spoken with felt the staffing levels were sufficient but indicated that there was occasions when staffing levels were reduced due to sickness or holiday and at these times it was said to be difficult to meet the social needs of the residents. One resident commented that, “ the staff don’t really get time to sit and chat, they’re very busy”. Twenty-three permanent care staff was employed at Stanton Hall. Of these nine staff had achieved a National Vocational Qualification (NVQ) at level 2 or above in care. Seven staff was at present undertaking NVQ training at level 2 or above. Therefore once these seven staff have achieved this qualification the home will Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 27 meet with the National Minimum targets set of 50 of the care team achieving an NVQ 2 or equivalent in care. Staff recruitment records and documentation was seen and in general all of the required documentation was in place, this included appropriate references. It was however noted that the homes application for employment form did not request a full employment history with any gaps in employment to be given in writing and must include the applicants reasons for leaving any positions were the applicant worked with vulnerable adults and/ or children. This was discussed with the registered manager who stated that she was not aware that this was now required. It was noted in one of the staff files seen that a full employment history had been provided by the member of staff. Staff induction and foundation training was provided for all new staff that came to work in the Home. All staff had an individual training and development assessment and profile. Training that had been undertaken within the last twelve months included; palliative care, food hygiene, safeguarding adults, fire safety, induction training and infection control. The manager confirmed that Moving and Handling training was due to be undertaken within the near future. Staff spoken with stated that the training provided was good. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and runs with the safety, welfare and best interests of residents foremost. EVIDENCE: The written information provided by Stanton Hall prior to this inspection stated that: The Registered Manager has a qualification in nursing and has acheived the Registered Managers Award level 4 NVQ. The Registered Manager keeps updated in changing practices in order to improve her knowledge, skills and competence. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 29 The Registered Manager ensures that Senior Staff are familiar with the aging process and diseases associated with the elderly through training and development. There is a business plan in place which is updated annually by the Registered Manager. Internal audits take place annually The home has acheived the Investors in People Award. A quality assurance system is in place and the information collated and improvements made where necessary. . The residents financial interests are safeguarded and documents maintained. The Registered Manager ensures that the health, safety and welfare of staff and residents are paramount at all times. On the day of the inspection visit: The manager has achieved the Registered Managers Award. Staff and residents spoken with were complimentary regarding the manager’s ability to run the home. At the last inspection visit 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. This is now being undertaken and records of these visits were seen. However it was difficult to read some of the information provided within these reports and is therefore suggested that these records be typed for clearer reference. Residents and one visitor that was spoken with reported that the home appears well managed, and that management and staff are available, approachable and communicate well with residents and visitors. Quality Assurance questionnaires were sent out to residents and their representatives every three months. The questionnaires focused on a particular service or care practice provided, such as meal times or activities. The results of these questionnaires were collated and available for residents and their representatives to see. Questionnaires were also sent out to visiting professionals and evidence of these returned questionnaires were seen. The system for handling residents’ personal monies was examined and there was confirmation that there are suitable accounting procedures in place. At the last inspection visit it was noted that the savings held for some residents were considerable, and the Manager was advised to reduce this to a Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 30 more reasonable amount. The manager confirmed that this has now been done. The guidance regarding care homes providing first aid has recently been amended and allows services to undertake a first aid risk assessment specific to their individual service. Information pertaining to the factors that can be taken into account and the criteria for who can be regarded as a qualified first aider were given to the manager at this inspection visit. As there are only four members of staff with a first aid qualification at Stanton Hall, the requirement regarding first aid that was made at the last inspection will remain in place, but will be amended to include the option of a first aid risk assessment being in place. However if a risk assessment is not in place the Commission will require that someone who has undertaken a suitably approved first aid at work qualification be on duty at all times. The records regarding fire safety were looked at; this included weekly and monthly fire checks including weekly fire alarm checks. Staff have undertaken fire training in February and March of this year and evidence was in place to demonstrate this. Measures were in place to reduce the risk of Legionella, and a hot and cold water valid sterilisation certificate was in place. In other respects, the service/maintenance documentation indicated that residents are protected by robust procedures, with all evidence of electrical services having been suitably checked/maintained, this included all moving and handling equipment such as hoists and lifts. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 31 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 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 3 X 3 X 3 X X 2 Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 32 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 OP9 Regulation 13 Requirement Risk assessments must be undertaken for all residents who wish to retain and selfadminister their medication to demonstrate that they have the capacity to do so safely. Employment application forms must request a full employment history, together with a satisfactory written explanation of any gaps in employment, and where a person previously worked in a position that involved contact with children or vulnerable adults, written verification as to why they ceased to work in that position. A suitably approved first aider must be on duty at all times unless a first aid risk assessment is in place that demonstrates the services first aid needs and how they are being met. (Previous timescale of 31/03/07 extended). Timescale for action 09/12/07 2. OP29 19 09/12/07 3. OP38 13 09/03/08 Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 33 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 OP25 Good Practice Recommendations Heating in bedrooms must always be provided at an appropriate level to allow Residents to return to their bedrooms at anytime during the day. 2. OP7 . The Manager needs to complete formal 6 monthly reviews 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. OP19 In one of the above toilets the cupboard below the washbasin needs repainting. 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. 4. OP26 At least one sluicing disinfector should be provided. A washing machine with a built in sluicing facility should be available for use to ensure hygiene and disinfection standards can be maintained. Stanton Hall DS0000002111.V341480.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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