Inspection on 04/06/07 for Stanton Lodge Nursing & Residential Home

This inspection was carried out on 4th June 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 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 Lodge Nursing &... 21/04/10

Stanton Lodge Nursing &... 26/01/10

Stanton Lodge Nursing &... 10/06/09

Stanton Lodge Nursing &... 06/08/08

Stanton Lodge Nursing &... 13/06/06

Stanton Lodge Nursing &... 14/11/05

Stanton Lodge Nursing &... 02/06/05

Stanton Lodge Nursing &... 07/12/04

Stanton Lodge Nursing &... 26/05/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Stanton Lodge Nursing & Residential Home Millfield Avenue Shiremoor Tyne & Wear NE27 0LE Lead Inspector Mary Blake Key Unannounced Inspection 09:30 4 & 21st June 2007 th X10029.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 Lodge Nursing & Residential Home DS0000029001.V338026.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 and Care Homes for Adults 18 – 65*. 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 Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanton Lodge Nursing & Residential Home Address Millfield Avenue Shiremoor Tyne & Wear NE27 0LE 0191 2522919 0191 2535017 stanton.lodge@fshc.co.uk www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Veronica Bernadette Cairns Care Home 72 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) Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (21) of places Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users are under pensionable age. No further admissions of under pensionable age service users must take place without prior agreement of the Commission for Social Care Inspection 13th June 2006 Date of last inspection Brief Description of the Service: Stanton Lodge is a purpose built 72 bed care home. All the accommodation is on ground floor level and all the bedrooms have en-suite facilities. The home is situated in a residential area and is close to local amenities and public transport. There are three units within the home each offering a different category of care, one provides for 20 older people requiring personal care, one provides 20 people requiring personal care with nursing and the third provides care for 21 younger physically disabled people. There are lounges and dining rooms on each unit and there is a smoking lounge. All units have specialist baths, showers and disabled toilets. There are enclosed garden areas, which are wheelchair accessible, and there are car-parking facilities. Fee rates vary from £363 to £490.This includes the nursing care element without specialist equipment. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two days and involved two inspectors. All of the key standards have been assessed during this visit and from other information provided to the Commission. A walk around the premises was carried out. Residents care records, staff records and additional statutory records were examined. Case tracking was undertaken, this involved following the care of individual residents. The Registered Manager, two nurses, four care staff and three ancillary staff were spoken to and the inspectors met sixteen residents and their families on their visit and spoke privately with eight. 2 resident and 2 relative questionnaires were received prior to the site visit. These were varied the majority being positive but some concerns expressed about availability of staff and unclear on how to make a complaint. This was shared with the Registered Manager at the inspection. The home is registered to provide care to people whose needs are within the older person and younger adults standards. Requirements set are generic unless stated. Of the previous 29 requirements set 4 remain outstanding with good progress being made. Two new requirements were set at this inspection. What the service does well: What has improved since the last inspection? The quality and presentation of the meals, the choices to residents and the organisation of the dining arrangements has been improved so that residents Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 6 can enjoy good food in pleasant surroundings. Menus are followed and residents receive a varied and balanced diet that is safely prepared and served. The homes refurbishment plan is going well and the home is furnished and decorated to a good standard and provides comfortable and pleasant surroundings for residents. Individual bedrooms are well furnished. New aids and adaptations assist the residents to move freely and independently around and outside of the home. The communal areas are now well decorated and used for a range of social events. The enclosed garden areas are improving and provide opportunity for residents to enjoy the outdoors and are landscaped to provide access for all residents. 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. The summary of this inspection report can be made available in other formats on request. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP3, 4 & 5 YA2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs fully assessed by care staff and have opportunities to visit before admission to the home. EVIDENCE: Pre-admission assessments are undertaken and reflect the needs of the residents. Care plans had good information to ensure that the home can meet the needs of the prospective resident. The Manager is involved in the decisions Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 9 and in the majority of instances visits the residents herself prior to their admission. Residents and relatives spoke of visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9 & 10 YA 9,19,20 &18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents are having their needs met by the staff in the home and the staff are skilled in providing the care in a sensitive and dignified manner. This is shown in the documentation and care plans in place. The care plans are detailed regarding the health and personal care needs of individual residents. There is good communication with other professionals to ensure residents health care needs are met. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 11 The residents receive their prescribed medication in line with safe working practices. These systems ensure that residents receive their medication in a safe and appropriate way. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Six care plans were examined; they were of generally of a good standard, with relevant risk assessments for the prevention of falls, nutrition, moving and assisting, continence promotion. The plans had been consistently reviewed and updated on a regular basis. The care plans showed that the residents have access to all NHS services and facilities if required. A number of assessment tools are in use. Daily reporting of residents care was satisfactory with any changing health care of residents being reviewed and updated in the care plan. The manager has taken steps to improve the care planning arrangements. Training is planned and records reviewed. There was evidence in the care plans of auditing by management. The medicines in the home are well managed and safely disposed. The medicines were stored safely. The controlled drugs procedures were satisfactory. Staff were treating residents with respect and dignity. Personal care was given in privacy. Staff used residents preferred name at all times. Relatives and residents were complimentary about the staff in the home and felt that they were able to have privacy in their own rooms Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14 & 15 YA 7, 11,12,13,14 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s social needs are being addressed and are documented. Residents maintain contact with family/friends/representatives and the local community as they wish. Residents are helped to exercise choice and control over their lives Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 13 Residents receive a choice from a wholesome, appealing; balanced diet and dining arrangements were well organised. EVIDENCE: The home has an activities co-ordinator who is very committed and enthusiastic. A good rapport between residents and the activities person was observed. The social activities co-ordinator is employed for 37 hours per week. Undertakes both group and individual activities. She has a diary so that the residents can book her time if they have things they want to do. There was evidence on an individual basis of the residents being involved in a number of varied activities, according to their abilities and choices. Residents enjoyed spending time in the recently improved garden area and others spent time in their bedrooms or watching television in the lounge. Two residents were spending time in one of their rooms and another went out shopping with the activities organiser. Visitors were observed to come and go throughout the day. Staff have a good rapport with relatives. Relatives felt positive about the staff and being made welcome when they visit. Residents handle their finances for as long as they can. People are able and encouraged to bring their own possessions and keepsakes from home and this was evident in resident’s bedrooms. There is evidence of improvement of the involvement of residents or relatives in their care plans. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. The residents are encouraged to go to places in the local area and families are encouraged and supported to take residents out and about. The residents’ bedrooms were personalised reflecting individual choices and preferences. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives were positive about the welcome they receive and the good communication between the home and families. The home now has the menu displayed and residents are asked for their choice for lunch and tea daily, which is recorded and given to the kitchen staff. The food being served was well presented, hot and well cooked. A number of Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 14 residents expressed their satisfaction with the improvements to the dining arrangements, the quality and choice of the food served and that they no longer have long waits. The cook understood the need to fortify the food for those residents who are at risk of or are actually losing weight. There was evidence that this was being done. There was butter, full fat milk etc. The cook stated what the choices are e.g. what kinds of soup and what kind of sandwiches so that the residents can make a more informed choice. Staff served the food and drinks to residents acknowledging their needs. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16 & 18 YA 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home ensures residents and relatives are aware of the complaints policy by making it available in a variety of places. Complaints are managed satisfactorily and the necessary action taken. Staff had an understanding of the Protection of Vulnerable adults, it was unclear if training had taken place and this is necessary to ensure that residents are protected. EVIDENCE: The complaints procedure is displayed in the home and available to each resident. The records of the complaints made to the home was examined and was satisfactory. Ten of the residents said that they knew problems were dealt with and how this would be done Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 16 The Registered Manager stated that staff were aware of the whistle blowing policy and informing the Manager of any incidents or issues of which there are concern. Staff confirmed this. Currently there are no allegations of abuse being investigated. The Registered Manager has attended a Protection of Vulnerable Adults (POVA) two-day training course but it was unclear if staff had undertaken this training. The policies and procedures for the Protection of Vulnerable Adults were examined at the previous inspection and were satisfactory. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,20,21,22,23 & 26 YA 24,25,26,27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a safe well-maintained environment. Residents live in comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is a single storey purpose build care home. The home is currently undergoing a vast refurbishment and redecoration programme, which is almost complete. Each unit has access to enclosed courtyards and garden areas. The areas are generally tidy and the younger residents were enjoying sitting in the warm sunshine in their nearly refurbished courtyard area. The communal areas has undergone refurbishment and the refurbishment programme has addressed the poor standard of carpets, décor and furnishings, which are much improved. The refurbishment of the bathing facilities is due for completion in August 2007. The plans to adapt bedrooms to enable full en-suite facilities with overhead tracking have been completed. Bedrooms are also undergoing refurbishment and carpets; fittings and redecoration are now almost complete in these areas. The residents have been encouraged to bring small personal items into the home making the bedrooms highly personalised. All of the bedrooms are single en-suite. The kitchen was clean and tidy. Recording was good. The constant buzzing from the nurse call system was a source of disturbance to residents, visitors and staff, residents commented “ I will never get used to it” “it gives me a headache” “it never stops” “it goes on all day and all night”. Staff were not appropriately responding to the emergency buzzer and this had become a background sound staff commented “I don’t really hear it now”. The home was very clean with no odours in the home on the day of inspection. The sluices were generally clean, with working disinfectors. Staff had access to liquid soap and paper towels in all areas. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29 & 30 YA 31,32,33,34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager ensures there are adequate numbers of staff on duty that have appropriate skills and experience to care for the residents. The recruitment processes in place protect residents. External and internal training takes place, but specialist training has not been completed and more that fifty percent of staff have not completed National Vocational Qualifications (NVQ) in Care Level 2 or above this does not always provide residents with a skilled, consistent staff team. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 20 EVIDENCE: Staffing rota and observation during the days indicated that the home is adequately staffed. The Registered Manager is supernumerary. There has been a low turnover of staff in the past year. Good ancillary support was in place. Staff undertake mandatory training, National Vocational Qualifications in Care and other training. This was clarified from the sample of records inspected and discussions with staff. Staff said that they are undertaking or had completed National Vocational Qualification in Care level 2 or over, this is progressing but still falls short of the fifty percent target. A staff training programme is not available; this should include the dates of completion for mandatory, POVA and NVQ and other training and confirms that the staff team have the skills and training to meet the needs of residents. The home has an induction and training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of residents. Staff recruitment files were examined and were satisfactory. Specialised staff training in relation to the needs and conditions of residents in the younger persons unit had not yet been completed, although the Registered Manager stated a training programme has been developed and is waiting implementation dates. Staff were observed being sensitive of the residents dignity and supportive to make them independent but providing care discreetly as necessary. One carer interviewed had a good understanding of the residents needs and knew about care plans and the importance of giving the senior staff any information about the changing needs or any problems. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,36 & 38 YA 8,23,36,37,39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 22 Residents live in a home, which is run and managed by an experienced person. The Manager has systems in place to organise the home taking into account the needs and wishes of the residents. Good quality systems have been established and are being developed. Resident’s financial interests are safeguarded but the pooling of residents monies has not been addressed. Progress is being made in staff supervisions. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: The residents and staff made positive comment about the Registered Manager and staff team; they gave examples of improved practices, one relative commented “I’ve been visiting the home for 10 years and it’s never been as good as this”. Regular meetings had been held for residents, relatives and staff. Quality assurance systems are currently under review. Monthly proprietor visits are undertaken with good written reports and any issues addressed. A company audit was undertaken in May 2007 this identified how the home was operating overall and what improvements were needed. Accidents are recorded effectively with accident analyses being completed and risk preventions being undertaken to safeguard residents. Staff supervision records showed a comprehensive process but that the timescales of six per year would not be met. The Registered Manager is currently addressing this. System testing had been undertaken and maintenance certificates were available. The company risk assessment identifies a number of fire risk issues, this included ramps at external fire exits of the younger persons unit and replacement of emergency lights. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 23 The nurse call system as well as being very disturbing to residents day and night is also not an effective system for dealing with emergencies. The call system goes into emergency system very quickly and staff were not responding, presuming it was the system, this presents a risk in the event of an actual emergency and must be addressed. The door numbering system is also confusing for residents, staff and visitors. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 24 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 X 2 X 3 3 4 3 5 X 6 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 ENVIRONMENT Standard No Score 19 3 20 3 21 2 22 2 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 2 36 3 37 3 38 2 Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP21 Regulation 23 Requirement The registered persons must ensure that bathrooms and shower rooms are repaired and refurbished to ensure there are sufficient bathing facilities to meet residents assessed needs. Timescale for action 31/08/07 2. OP28 18 Timescale of 310706 but good progress being made and completion date of 310807 The registered persons must 31/10/07 ensure that 50 of care staff are trained to NVQ level 2. Timescale of 31/10/06 not met but progress being made The registered persons must ensure that specialist training is provided for all staff to ensure they can meet the residents’ needs. Outstanding 02/06/05. Timescales of 31/01/06 and 31/10/06 not met. Progress being made and the training plan must be submitted to CSCI 3. OP30 12(1) 13(4) 18 31/08/07 Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 26 4 OP35 12,20 The registered persons must ensure that where they hold personal allowances for individual residents any interest accrued is paid into their account. Timescale 31/01/06 and 01/09/06 not met being addressed at provider level The nurse call system must be reviewed/replaced with a system which addresses the following a) Emergency alarms which allows appropriate staff response b) Emergency alarms which gives reassurance to residents c) A call system which is unitised and does not ring constantly disturbing all residents day and night To address fire issues identified within their risk assessment including a) Ramps not in place to external fire doors in physical disability unit. b) Complete remedial action to fire alarm/emergency lights c) Meet the issues identified in the fire prevention officer visit of 10/06 31/10/07 5 OP22 13 (4) (c) 23 (2) (n) 31/10/07 6 OP38 13 (4) (a) 23(4) (a) (b)(c) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations Holidays should be considered for the younger residents as part of the contract price. DS0000029001.V338026.R01.S.doc Version 5.2 Page 27 Stanton Lodge Nursing & Residential Home 2. YA22 Consideration should be given to providing the complaints procedure and care plans in alternative formats. Stanton Lodge Nursing & Residential Home DS0000029001.V338026.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. Extracts may not be used or reproduced without the express permission of CSCI. 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