Inspection on 10/10/05 for Stanton Manor

This inspection was carried out on 10th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stanton Manor 21/11/08

Stanton Manor 03/12/07

Stanton Manor 13/06/07

Stanton Manor 06/06/06

Stanton Manor 23/06/05

Stanton Manor 28/09/04

Stanton Manor 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Stanton Manor Piddocks Road Stanton Burton On Trent Staffordshire DE15 9TG Lead Inspector Jo Wright Unannounced Inspection 10th October 2005 09:00 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 Manor DS0000020098.V256178.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 Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stanton Manor Address Piddocks Road Stanton Burton On Trent Staffordshire DE15 9TG (01283) 565447 01283 565447 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) Mrs Pamela Mary Mycroft Mrs Pamela Mary Mycroft Care Home 28 Category(ies) of Dementia - over 65 years of age (28) registration, with number of places Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 places for service users under the age of 65 years as named in the notice of proposal: 23rd June 2005 Date of last inspection Brief Description of the Service: Stanton Manor is a care home registered to provide personal care and accomodation for up to 28 people in the category of older persons with dementia. The home is siuated in its own extensive and well maintained grounds. The nearest town is Burton on Trent, which is about 10 minutes drive from the home. Stanton Manor has both single and shared rooms, some of which have ensuite facilities. The home consists of two separate units, the main house and The Mews, which is located across the court yard. Bedrooms are situated on the ground and first floor. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in order to investigate issues raised in a complaint received by the Commission. These were reduced staffing levels and not taking appropriate action when residents were ill. The issue of reduced staffing levels was upheld. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users) were not examined in depth during this inspection, as the timescale on the requirements relating to these had not been reached. Other records such as complaints, servicing of equipment records and medication records were examined. An assessment was made with respect to the requirements made at the last inspection of this service. The manager was present at the inspection, and the findings from the complaint and the inspection were discussed with her. What the service does well: What has improved since the last inspection? What they could do better: Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 6 Staff practice in relation to administration of medication needs to improve. There are no guarantees at present that residents will receive their medication as prescribed and this puts them at risk of not having their health care needs met. Staff need to record all action taken to cover any shortfalls in shifts, otherwise it appears that no action was taken, and residents and staff were put at risk by insufficient staffing cover. The service would benefit from more emphasis on quality assurance and quality monitoring with a view to continuous improvement. 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 Manor DS0000020098.V256178.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 Manor DS0000020098.V256178.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): 4 Although efforts have been made to provide staff training, the staff team as a whole did not have the necessary skills and knowledge to fully meet residents needs. EVIDENCE: Progress had been made towards meeting the requirement (not time expired) to provide staff with training that was resident specific and met the needs of the current resident group. The manager had attended training on communication and challenging behaviour, and had planned a training session on this for her staff. Staff had also attended training on challenging behaviour. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The care plans did not provide a clear picture of the individual residents or how their needs would be met. The systems for administration of medication were poor and placed residents at risk of not having their health care needs met. EVIDENCE: Residents files were not examined in detail as part of this inspection, although the care plans and daily logs for a number for residents were examined briefly. It was noted that progress towards meeting the requirements (not time expired) relating to residents files had been made. A new care plan format had been introduced and the care plans for all of the residents had been reviewed and rewritten. Staff had made efforts to develop care plans for all identified needs. Not all care plans examined set out the preferences and abilities of the resident, or contained sufficient detail for staff to provide appropriate care to fully the resident’s needs. Staff require further support and guidance in this aspect of their work. There was limited evidence in the files to support that residents had been involved in the care planning and review process. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 10 The recording of accidents and incidents had improved. The manager had worked closely with the community nurses to assess those residents identified as at risk of falls, in order to identify individuals who require referral to other health care professionals. Staff were completing appropriate forms for residents who had accidents, or how had unexplained injuries, such as bruising or cuts. The manager audited the information recorded and signed off these forms. The management of medication was poor, even though staff responsible for administration of medication received training provided by ‘Boots the Chemist’ in September 2005. This poor practice puts residents at risk of not having their health care needs fully met. Staff practice was inconsistent, which resulted in residents not receiving their medication as prescribed. It was noted for a number of residents that medication had been signed for and not given, given and not signed for, or not given and no reason for non-administration recorded. The medication for Monday night of week 1 had not been given, due to the new medication packs been sent back to the pharmacy by mistake. However, not all of this medication remained in the medication packs, as would be expected. This was discussed with the manager and deputy manager during the inspection. The manager was asked to investigate this matter in more depth, to establish where the missing medication had gone. The time of administration of one medication had been changed from morning to night, but the date of this change was not recorded. The code ‘F’ was recorded on charts, but the reason for non-administration had not been recorded. A dedicated medication refrigerator was not provided, and medication requiring cold storage was kept in the refrigerator in the kitchen. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 An adequate activities and social programme provided varied and interesting opportunities for residents. A varied range of meals and alternatives were provided, offering residents a choice and a balanced diet. EVIDENCE: Residents spoken with commented that they were happy living at the home, and one resident commented that they liked their bedroom. Residents commented about being able to choose when they went to bed and got up in the morning. However, these residents needed minimal assistance from staff. However, it was not possible on the evidence gathered during this inspection to make a judgement on whether those residents who required more assistance were able to exercise choice and control and make decisions about their care. The home provides a range of activities for residents. The manager acknowledged that more activities were arranged in the Mews, as these residents were more able to participate. Activities such as board games and indoor games were organised by staff. Photographs of a recent visit by a professional entertainer were available. Residents commented that they had enjoyed this. Residents were encouraged to continue with existing hobbies and activities, and one resident spoken with commented that they regularly Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 12 went out to church with their friends. Residents were also visited by the library service every four weeks. There were some limitations to when people could visit, but these were around meal times, so that residents were able to have their meals undisturbed. Residents and relatives spoken with were aware of these limitations. One visitor spoken with commented that they were welcomed with they visited. Residents spoken with did not raise any issues about the meals provided at the home, and commented that the meals were good. Planned menus were in place, and any specialist diets catered for. Support and assistance at meal times was provided as required. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 13 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): 16 and 18 A complaints procedure was in place, with confirmation from residents that they feel able to raise issues with the manager. Procedures were being strengthened to protect residents from abuse. EVIDENCE: The complaints procedure was on display. Those residents and relatives spoken with indicated that they would speak with the manager if they had any concerns. The manager reported that she had not received any internal complaints. The Commission had received one complaint in June 2005, which resulted in a referral being made through the local authority Protection of Vulnerable Adults procedures. These issues raised at that time are detailed in the previous inspection report. The Commission received another complaint in September 2005, which has been investigated during this inspection. The issues related to reduced staffing levels and the manager reacting slowly when residents were ill. The issue relating to staffing levels was upheld (see section on Staffing). Discussion took place with the manager about the two residents named in the complaint. The manager reported that both residents had been seen by their GP and admitted to hospital for further treatment. It was not possible to establish whether residents were seen in a timely manner when they were ill. Progress had been made towards meeting the requirements (not time expired) to make staff fully aware of policies and procedures relating to the protection Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 14 of vulnerable adults, whistleblowing and restraint, and providing training on recognising abuse and the protection of vulnerable adults. Staff were provided with the polices and procedures as outlined in the requirement following the last inspection. The manager had attended a two day training course provided by the local authority of The Protection of Vulnerable Adults, which enabled her to train the staff group. This training for staff had been arranged for 3 November 2005. Training on communication and challenging behaviour had also been arranged for 18 October 2005. Staff knowledge on these policies and procedures was not checked during this inspection. Stanton Manor DS0000020098.V256178.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 and 26 Stanton Manor provides as comfortable and homely environment for residents. EVIDENCE: Stanton Manor provides a comfortable and well maintained environment for residents. All areas were clean, tidy and free from odour at the time of this inspection. There was evidence of ongoing decoration and refurbishment in bedrooms. People had been encouraged and enabled to personalise their rooms with their own belongings. Residents had access to a number of communal areas, and all areas were well used during this inspection. Residents also have access to a enclosed well tended garden. Although a limited range of bathing facilities were provided, the manager reported that there were plans to upgrade the ground floor bathroom so that a fixed bath hoist could be installed, and upgrade the bathroom on the first floor and install a walk in shower. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 16 Systems were in place for laundering and returning personal clothing. The laundry equipment was in good working order. However, the manager acknowledged that the washing machine did not have a sluicing cycle or disinfection standards. Stanton Manor DS0000020098.V256178.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): 27, 28 and 29 Planned staffing levels were appropriate for the number of residents and the category of the care home, although these levels were not always achieved. There were on-going arrangements to provide appropriately trained care staff to meet the needs of the residents. EVIDENCE: Stanton Manor is experiencing ongoing issues with retain of staff. Since the last inspection in June 2005, 12 members of staff have left their employment. 10 of these people were employed as care assistants, and 5 of them had NVQ Level 2 or equivalent. Use had been made of agency staff to cover any planned shortfalls in staffing levels. The manager reported that she has recruited two additional members of staff, both of which have NVQ Level 3. However, over 50 of the care staff had achieved NVQ Level 2 or equivalent. The home aims to provide 5 care staff on duty during the morning shift, and 4 care staff on duty during the afternoon shift. Two members of staff are roistered to work in the Mews during the morning and afternoon. Three members of waking night staff were provided. Deployment of staff had improved, with senior staff allocated to work in each unit, rather than together when on duty. The complaint received by the Commission related to staffing levels on 18th September 2005. The complaint was that only two members of staff were on Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 18 duty when there should have been four, resulting in one member of staff being on duty in the Mews. This had occurred because staff had called in sick and had not been replaced. The manager stated that she was holiday on this date. The duty rota showed that four staff had been roistered on duty for both the morning and the afternoon shift. Two members of staff rang in sick for the morning shift, leaving two members of care staff and the member of staff who was cooking (who also works as a care assistant). There was no documented evidence to indicate that the most senior member of staff on duty had taken any action to cover this short fall in staffing hours. Therefore, on the evidence available, this complaint is upheld. The manager indicated that she thought that the member of staff concerned would have tried to cover the shifts, and agreed to speak with the member of staff to establish what action was taken at the time. This complaint also highlighted that the duty rota did not accurately reflect that the hours that the manager works, as the rota did not indicate that the manager was on holiday. Staff files were not examined during this inspection. The manager confirmed that application forms were completed for each period of employment at the home, and two written references were obtained. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Whilst the home is generally run in the best interests of the residents, there is a lack of formal quality assurance and quality monitoring to provide the basis for improving the service for the residents and ensuring that care is always of a high standard. The safe working practices and financial systems promote the health, safety and best interests of residents. EVIDENCE: Mrs Mycroft, has been the owner/manager of Stanton Manor for a number of years. Mrs Mycroft is a qualified nurse, and NVQ Assessor. Mrs Mycroft had updated her knowledge by attending a number of training events this year. The views of the people living at the home or their families were not sought on a formal basis, either through quality assurance systems such as questionnaires, or residents/relatives meetings. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 20 Systems were in place for the safe keeping of residents money. The amount held and the records for three residents were checked and found to be correct. Training in safe working practices was provided. However, the manager acknowledged that there was no clear system in place for recording and monitoring staff attendance at training. The manager planned to address this by developing a training matrix and establishing the individual training needs of staff through supervision. A sample of service/maintenance records was examined (including equipment, gas and fire alarm system) and there was confirmation that equipment and services were properly maintained. However, the records did not support that the fire alarm had been tested on a weekly basis. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 22 No 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 OP4 Regulation 18(1)(a) Requirement Timescale for action 31/10/05 2 OP7 3 OP7 4 OP8 5 OP9 The Registered Person must provide staff with training that is resident specific and meets the assessed needs of current resident group. 15(1) The Registered Person must ensure that all residents have care plans that set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met 15(2)(c) & The records must demonstrate (d) that the resident and/representative had been involved in the care planning and review process. 12(1) The Registered Person must 13(4) ensure that the relevant general 14(1) and individual risk assessments are completed for all residents and appropriate action taken recorded, depending on the outcome of assessment. (Previous timescale of 28 February 2005 not met) 13(2) Residents must receive the 17(1)(a) medication that they are DS0000020098.V256178.R01.S.doc 31/10/05 30/11/05 31/10/05 30/11/05 Stanton Manor Version 5.0 Page 23 Sch 3 6 OP9 13(2) 7 OP9 13(2) 8 9 OP9 OP14 13(2) 12(2) 10 OP18 13(6) 11 OP18 13(6) 18(1)(a) (c) 18(1)(a) 12 OP27 13 OP33 24 prescribed. Reasons for nonadministration must be recorded on the medication chart. The manager must investigate what happened to the medication that was not given on Monday of week 1, that had been removed from the medication packs. Staff must not alter the instructions on the Medication Administration Records (MAR) unless instructed to do so by the GP. This information must be recorded on the MAR and signed and dated by the member of staff or the GP. A dedicated lockable medication refrigerator must be provided. The Registered Person must ensure that the home is run in a manner that enables residents to make decisions with respect to the care that they receive and their health and welfare. The Registered Person must ensure that staff are fully aware policies and procedures relating to the protection of vulnerable adults, whistleblowing and restraint, and work within these procedures. All staff must attend training on recognising abuse and the protection of vulnerable adults (including the local authority procedure). Adequate staffing levels to meet the needs of the residents must be provided. Records must support that all efforts have been made to cover any shortfalls. A system for reviewing, and where necessary improving the quality of the service must be established and maintained and the results of findings e.g. DS0000020098.V256178.R01.S.doc 30/11/05 30/11/05 31/03/06 31/10/05 31/10/05 31/10/05 30/11/05 31/03/06 Stanton Manor Version 5.0 Page 24 14 OP38 23(4) satisfaction surveys, made public. The fire alarm must be tested on a weekly basis and this information recorded. 30/11/05 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 OP27 Good Practice Recommendations The duty rota should accurately reflect the hours that the manager works in the home. Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stanton Manor DS0000020098.V256178.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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