Inspection on 03/12/07 for Stanton Manor

This inspection was carried out on 3rd December 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 Manor 21/11/08

Stanton Manor 13/06/07

Stanton Manor 06/06/06

Stanton Manor 10/10/05

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 Helen Macukiewicz Unannounced Inspection 3rd December 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stanton Manor DS0000020098.V355130.R02.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 Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanton Manor Address Piddocks Road Stanton Burton On Trent Staffordshire DE15 9TG (01283) 565447 01283 565447 stantonmanor@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) Mrs Pamela Mary Mycroft Mrs Pamela Mary Mycroft Care Home 28 Category(ies) of Dementia (28) registration, with number of places Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only:Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home is within the following category:2. Dementia - Code DE The maximum number of service users who can be accommodated is: 28 13th June 2007 Date of last inspection Brief Description of the Service: Stanton Manor is a care home registered to provide personal care and accommodation for up to 28 people in the category of older persons with dementia. The home is situated 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. Information about the service is provided through the Statement of Purpose and Service User Guide. The last information about the fees was received on 10/05/06. The fees for Stanton Manor at that time were between £300 and £410 per week. A note in the statement of purpose for the home says that the Inspection reports are kept in the Managers office if anyone wants to read them. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 7 hours during one day. No preinspection questionnaires were received from people living in the home before this Inspection, but one was received from a Care Manager. Findings from this questionnaire are included in this report. The Manager had completed a self-assessment of the home and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Due to the nature of the client group, and their inability to provide much meaningful feedback about their care, two hours was spent observing staff interactions with residents using a recognised method. These observations focused on how much time staff spent in meaningful interaction with residents, whether their communication had a positive effect on people, and how much activity they engaged in. The findings of these observations are contained within this report. Time was spent in discussion with the Manager and staff. Three residents care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as training records and staffing rotas. A brief tour of the home took place including some bedrooms. An ‘expert by experience’ assisted with the inspection process. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ was present for two hours and spoke with several residents and a relative. Her findings are incorporated into the report. What the service does well: Documentation and feedback from visiting relatives supported that a good admission process is followed. One relative said ‘I’m quite satisfied’ Most of the residents appeared to be very well kept, clean and well dressed and the ladies had enjoyed regular hairdressing to keep them looking smart. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 6 Relatives confirmed that staff are respectful in their communications with residents and that privacy is maintained. Comments included ‘my mother is always clean and well dressed’. Relatives confirmed that they can visit in private if they wish. One said ‘on the whole they do a good job’. One care manager recorded that the home ‘provides excellent levels of care for all’. Relatives were happy with the homes’ complaints procedures and felt that the Manager would sort things out. It was clear that residents have a positive relationship with staff and most staff were positive in their communication with them. What has improved since the last inspection? What they could do better: The way that care needs are identified and planned for could be improved. Some residents need re-assessing as they may no longer be suitable to be cared for within the registration category of the home. There are high demands on staff time and so physical needs tend to be prioritised over social care needs during busier times of the day. Staff were Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 7 busy carrying out tasks that met peoples’ physical needs during the morning, which left little time for activity, person centred care and social care. Staff had started to assist residents to the dining table for up to one hour before lunch was served. This led to complaints by residents and people getting up and wandering away from the table. A specialist chair was being used; a more detailed assessment and care plan for this equipment was needed. Several issues were affecting staff’s ability to provide quality care during the day of the Inspection. The fact that residents dependencies had risen and that staffing numbers had not risen to account for this and the fact that there have been several new members of staff employed who are not yet experienced in this care setting. Also the mix of residents in the Mews needed review as some had higher levels of need and it was also apparent that some residents did not get along because of their needs. There was a couple of examples seen whereby staff did not use a person centred approach in their communications with each other in front of residents, and a couple of times, to residents themselves. 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 Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 8 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.V355130.R02.S.doc Version 5.2 Page 9 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): Standards 1 and 3. Standard 6 does not apply, the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to choose a home that will meet their needs. EVIDENCE: The information about the home has been updated since the last Inspection and was available to see. In her completed pre-inspection self-assessment, the manager recorded that she is a registered nurse and assesses all clients before they are admitted. She stated that she acquires a care plan off Social Services, or The Mental Health team, then visits people in hospital or at Home, or they visit the Home. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 10 The client , relative or advocate are given a pre assessment questionaire to fill in. The home also admits respite care, which can be anything from one week to a month. The same criteria still applies. The staff are trained in all areas’. During this Inspection, the documentation and feedback from visiting relatives supported that this process is followed. One relative said ‘I’m quite satisfied’. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most people receive the care they need in a private and dignified way although there is the potential for some care needs to be missed. EVIDENCE: The care files that were seen all contained assessments of need and a plan of care that was based upon that assessment. Care files were generally well kept and contained all the essential basic information that is required. Risk assessments were in place and there was evidence to support that both risk assessments and care plans are reviewed on a regular basis. The following improvements are needed. Two risk assessments for skin care didn’t have the resident’s name on, as there was no space allocated for this information. Some care that had been given had been documented only on the daily information sheets and not updated into the plan of care. Care plans in certain areas were not sufficiently detailed such as for people who might Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 12 exhibit challenging behaviour, those with continence needs or who smoke and need this to be monitored. Social care plans were not well developed. Although there was evidence that relatives had been involved in planning some of the residents care, care plans had not been ‘signed off’ as having been agreed by residents or their advocates. Care files, information around the home and the Manager all supported that residents receive the services of the G.P, district nurses, optician, dentist and chiropodist as well as specialist mental health services and health professionals. The Manager has identified that some of the residents had become more dependent and had a higher level of physical need. She had identified some whose needs required re-assessing. She had started a process to do this. Observations of the actual care given to residents showed that staff were mostly meeting their basic health care needs. However, physical needs tended to be prioritised over social care needs during busier times of the day (see next section in this report for further detail). One resident had not been attended to for a period of almost 2 hours and had been incontinent when staff came to assist them to the table for lunch. This is an example where extra demands on staff time are affecting their ability to provide care to meet everyone’s needs. (see section under staffing). Most of the residents appeared to be very well kept, clean and well dressed and the ladies had enjoyed regular hairdressing to keep them looking smart. Since the last Inspection the Manager has written to the Commission for Social Care Inspection to confirm that she has sought advice from her local pharmacist and has put measures in place to ensure better management of controlled drugs and creams that are kept in people’s own rooms. She has fitted locks to cupboards in bedrooms so people can store their medicines safely. Where checked, these measures were effective in ensuring the safety of residents. Improvements were also noted more generally in terms of the management of medicines and staff confirmed that new systems were working much better. Staff who administer medicines have all had training and records of medicines given were satisfactory. Relatives confirmed that staff are respectful in their communications with residents and that privacy is maintained. Comments included ‘my mother is always clean and well dressed’. Relatives confirmed that they can visit in private if they wish. One said ‘on the whole they do a good job’. One care manager recorded that the home ‘provides excellent levels of care for all’. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 13 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): Standards 12-15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people living in the home lead a varied lifestyle of their choosing although most people less able to communicate/participate have restricted choice, which means they have less rights within the home. EVIDENCE: About two hours was spent observing people in the lounge areas to see what the levels of activity were during a given time frame. Staff were busy carrying out tasks that met peoples’ physical needs during the morning, which left little time for activity, person centred care and social care. Most residents in the main lounge were either asleep or just sitting, staff were going to and fro carrying out tasks but no-one spent any time sitting and chatting to residents or offering any social activity/stimulation. There was feedback from some residents and relatives that some activities do take place. The Manager stated that the day of Inspection was not reflective of usual care practices as there was a study event planned which took staff away from spending time with residents. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 14 By contrast the dining room was busy with talkative service users. They were delighted to have a visitor. Two members of staff were in the room, one spoon feeding a lady with tea, and the other chatting to another lady. One lady was knitting, but she was the only one with any activity. One lady said she went to the shops sometimes. They knew they were going to be making Christmas cards soon and when asked who was going to help them make the cards, they pointed to another service user and said she was very good at drawing. One resident said she went into the local town to do some cooking, so there may be an activity drop in centre which is used, and coach trips to Twycross zoo also were mentioned. The residents were quite excited because the Christmas tree had been put up and when asked if they had a good time at Christmas, one said the dinner was ‘marvellous’. Another said a man came with an organ and they could sing. Care plans did support that an assessment of social needs had been made, and that staff had actively sought information from relatives about the residents’ likes/dislikes/ daily routines and hobbies. However, care plans and daily logs were lacking in detail about social care and activities provided. These did not support regular activity or state how staff were going to meet social needs in a person-centred way. In her completed pre-inspection questionnaire the manager said that as a result of listening to people who use the service, ‘we have Changed menus. (Filed in the kitchen). Purchased a DVD player and films.(In the lounge). Purchased more plants flowers for the garden. Acquired two cats. Have acquired the services of a masseur who gives the clients one to one, hand massage.’ She also stated ‘we plan to Arrange some shopping trips and gardening centre trips and arrange a different organist for our Coffee mornings’. Residents said they enjoy the meals offered. However, on the day of the Inspection, staff had started to assist residents to the dining table for up to one hour before lunch was served. This led to complaints by residents and people getting up and wandering away from the table. Although the Manager stated that again, this was not usual practice, feedback from residents themselves supported that they do have to wait in the dining room for too long before lunch. Staff assisting people with a high level of physical needs was also holding up lunch. Most staff were assisting people with their meals in a person centred way although one resident was being assisted in a hurried manner. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 15 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are kept safe in the home and their rights to complain are upheld by the homes’ procedures. EVIDENCE: No complaints have been made to the Commission for Social Care Inspection about the service since the last Inspection. The manager confirmed that she had received no complaints. Relatives were happy with the homes’ complaints procedures and felt that the Manager would sort things out. The Manager confirmed that all staff have now received safeguarding training. She had identified that staff needed training on the Mental Capacity Act and had a resource file about this. Documentation for consent to use equipment that carries a degree of restraint was in place, alongside a risk assessment. A specialist chair was being used; a more detailed assessment and care plan for this equipment was needed although consent had been obtained. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 16 During the last Inspection in June 2007, training certificates shown to the inspector demonstrated that an adequate number of staff had received safeguarding adults training. Staff who spoke with the inspector also demonstrated an awareness of what to do to ensure the safety and well being of service users in their care. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 17 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): Standards 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home that meets their needs. EVIDENCE: In her pre-inspection self-assessment the manager said that as a result of listening to people ‘we have Changed the use of a bathroom to shower room. We plan to Have the road repaired leading to the property; Have a ramp installed to the car park; Change dining table covers; Have a conservatory built and buy some more seating for the garden’. One of the Inspectors noticed that tablecloths needed replacing and that the new ones were put onto dining tables during this Inspection. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 18 There was two parts to the main house, a lounge with a circle of chairs and a TV, and the dining room with tables with chairs around them. The latter was used as a meeting and chatting place by the residents as well as a room in which had their meals. The dining room was noticeably cold and draughty and two residents openly complained about it being cold prior to lunch. During lunch this room had become warmer, but the Manager should monitor this. The Mews Bungalow accommodates 8 of the 28 residents. This was well furnished and very pleasant with large windows. There was a washing machine in the dining kitchen and a living area with soft seating. It was noted that the plastic table cloth was full of cigarette burns and there a smell of smoking in the air. The manger confirmed that the residents do smoke in there even though the policy is that they should not. The current arrangements do not comply with new anti-smoking legislation. Relatives said they found the home clean. The washing machine does not have a sluice cycle. The Manager is aware what is required in order to provide adequate laundering facilities and has identified a new washing machine for future expenditure. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 19 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): Standards 27-30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are cared for by staff who are trained and competent to do their job, although numbers of staff on duty do not allow for all care needs to be met. EVIDENCE: In the managers pre-inspection self-assessment she stated that improvements have been made since the last inspection in the following areas: ‘Staff have been recruited with regard to mixed skills and gender. Staff files have been updated by the new administrator and are being reviewed on a regular basis. The staff percentage for NVQ training is increasing. We have a better retainment of staff. Staff attendance for training has improved’. She also recorded that all staff have had training in infection control. Just under 50 of all staff have National Vocational Qualifications (NVQ) to level II or above, some are due to complete this and the remainder are due to commence the course in January 2008. Several issues were affecting staff’s ability to provide quality care during the day of the Inspection. The fact that residents dependencies had risen and that staffing numbers had not risen to account for this and the fact that there have Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 20 been several new members of staff employed who are not yet experienced in this care setting. One newer member of staff was alone in the Mews caring for 8 residents. Some of whom had complex and challenging needs. Also the mix of residents in the Mews needed review as some had higher levels of need and it was also apparent that some residents did not get along because of their needs. The Manager had acknowledged these issues and had made a start to address these. However, more direct action is required either to find more appropriate placements for some people, or to amend the homes’ statement of purpose and provide more staff to accommodate existing residents. On the last Inspection that took place in June 2007, staff training and induction was found to be satisfactory. There was evidence that staff receive induction on this Inspection and that there has been further training for all staff. It was clear that residents have a positive relationship with staff and most staff were positive in their communication with them. There was a couple of examples seen whereby staff did not use a person centred approach in their communications with each other in front of residents, and a couple of times, to residents themselves. The manager also wrote to the Commission for Social Care Inspection to say that she has improved staff recruitment files so that all the required information is now kept and that people living in the home are better protected. She now obtains criminal record checks on staff through a recognised body, which has helped to speed up the process. Three recruitment files for new staff were seen and were satisfactory. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of people living there so they are safe. EVIDENCE: The Manager is a Registered nurse and qualified assessor for NVQ training. She has worked in residential homes looking after the elderly for nineteen years, and forty-one years as a qualified nurse. She confirmed in her preinspection self-assessment that she keeps herself up to date on all Statutory training, and also other training that is relevant to client users. The Manager also recorded that the Deputy Manager is awaiting certification for NVQ level 4, and another senior member of staff undertaking level 4 NVQ. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 22 The Manager is aware that she needs to undertake a Registered Managers award although her aim is to progress her deputy and assistant managers through this award in 2008. She also confirmed that policies and procedures are kept up to date and reviewed regularly, stating ‘We have safe working practices with all relevant policies in place’. The system for managing residents finances appeared satisfactory, documentation was in place and had been audited, receipts for purchases are kept. The Manager prefers not to manage money on their behalf. In terms of quality assurance, the manager stated in her self-assessment that ‘We hold client meetings, seperately and as a group. We conduct Annual Questionaires.’ At the last Inspection in June 2007, the Inspector saw evidence that customer satisfaction surveys had been used, and there was also evidence that the Manager had taken action on points that had been raised. One of the relatives confirmed that she had been asked to complete a questionnaire. Again, at the last Inspection service records for equipment used around the home were in place and up to date. This ensures the safety of people living at the home. The manager is taking action to address issues raised at the last fire officers’ inspection. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement Care plans must contain clear and detailed information for staff to be able to carry out care, and be updated as needs change. Care plans must be developed to identify social needs and how staff are to meet those needs. Care plans must demonstrate that they have been devised in consultation with residents/advocates. Residents in the Mews must have their needs reviewed taking into account the mix of personalities/needs of the existing group of residents there. If necessary a review of accommodation must occur. Residents/advocates must be 31/01/08 consulted about social activity and preferred daily routines, and a social/activity programme must be put in place to meet identified needs. Lunch times must be planned to 31/01/08 meet needs of residents and prevent lengthy waiting times. DS0000020098.V355130.R02.S.doc Version 5.2 Page 25 Timescale for action 31/01/08 2. OP12 16(n) 3. OP15 16(i) Stanton Manor 4. OP18 13(7) 5 OP27 18(1)(a) Equipment that carries a degree of restraint must be used following adequate assessment of need and care plans must support this is subject to regular review and that appropriate consent has been obtained. There must be enough staff to ensure residents care needs can be met. 31/12/07 31/12/07 6 OP30 Staffing levels must be based on the current dependency levels of residents at the home. 18(1)(a)(c Staff must receive training on ) person centred care. 28/02/08 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. 2. 3. 4. 5 6 7 Refer to Standard OP7 OP7 OP15 OP19 OP19 OP28 OP26 Good Practice Recommendations A record of all social care/activities provided to residents should be kept in their file to support the level of activity provided by the home. All care plans should be ‘signed off’ as agreed by residents/advocates. Residents should be assisted to eat in a dignified way. The temperature of the dining room should be monitored and residents consulted to ensure it is warm enough for them. Smoke free legislation should be adhered to. The manager should continue efforts to ensure a minimum of 50 of the staff have NVQ level II or above. A washing machine with sluice cycle should be purchased. Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Stanton Manor DS0000020098.V355130.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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