Inspection on 31/01/06 for Stanway Green Lodge

This inspection was carried out on 31st January 2006.

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

Other inspections for this house

Stanway Green Lodge 17/10/07

Stanway Green Lodge 28/11/06

Stanway Green Lodge 22/09/05

Stanway Green Lodge 21/06/05

Stanway Green Lodge 19/10/04

Stanway Green Lodge 15/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Stanway Green Lodge Stanway Green Stanway Colchester Essex CO3 0RA Lead Inspector Tim Thornton-Jones Unannounced Inspection 31st January 2006 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 Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stanway Green Lodge Address Stanway Green Stanway Colchester Essex CO3 0RA 01206 330780 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 Laura Kanitkar Mrs Ann Carey Barlow Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) The registered manager must complete the Registered Manager’s Award within 12 months from the date of this certificate 22nd September 2005 Date of last inspection Brief Description of the Service: The care home provides personal care and accommodation to people over the age of 65, who require such care by way of their older age and the conditions associated with aging. This does not include care for any specific category of service, such as dementia or any other condition excluded from the current registration category for the home. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken, by Inspectors T Thornton-Jones and G Elvin, as part of the statutory inspection programme and to follow up previous inspections of this service and monitor required improvements. Since the previous inspection a Manager had been appointed, Mrs A Barlow, who has subsequently registered with CSCI. This inspection concluded that some improvements were noted and this is a positive development. The degree of remaining improvement that is required remains significant, with a high proportion of National Minimum Standards still to be achieved. At the previous inspection 27 National Minimum Standards were unmet. This represented an overall compliance level of approximately 29 , with 20 standards (74 ) being carried forward from the inspection previously. At this inspection previous shortfalls were again inspected and also standards not inspected at the last visit. Of the previous 27 non-compliant standards, assessed at the last inspection, 9 now comply, thereby leaving 18 standards yet to be achieved. Of those 18 standards, 13 had been carried forward. The total number of standards reviewed on this occasion was 32, of these 12 complied with National Minimum Standards. This represents approximately 37.5 of the standards assessed. This compares with compliance of 29 previously. This represents an improvement, particularly in relation to several standards previously rated at level 1, now having improved and rated at level 2, although these fall short of a satisfactory level of practice in relation to National Minimum Standards. The Registered Person will need to ensure that all standards rated below level 3 receive attention since the majority are persistently failing to meet satisfactory levels of professional practice. This service remains within the ‘high risk’ group and further improvements will need to be made. CSCI will request the Registered Persons to revise their action plan as a result of this inspection and present the plan again to CSCI with a view to ensure a speedy and progressive recovery. What the service does well: • • The service maintains a spacious environment. The gardens and grounds are well maintained.* Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 6 • • Some examples of good practice are being maintained by some care workers. Arrangements for social inclusion and activities for service users. * Notwithstanding requirements and recommendations set out within this report. What has improved since the last inspection? 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. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 • • • • Service users do not adequately benefit from information they need to know how the home is able to meet their assessed needs. Contractual arrangements remain below the standard required. The home was unable to demonstrate that the service is able to meet individual needs, prior to admission or of those currently accommodated. The service was not registered to provide intermediate care and therefore this standard was not fully assessed. EVIDENCE: The Statement of Purpose document had been revised since the previous inspection and now makes reference to all of the areas required by regulation. Some of the information was, however, limited in detail and would benefit from further development. See recommendations. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 9 The Service Users Guide document needs further development to ensure that all required information has been included, for example; the most recent inspection report and a summary of the view of service users about the home. Arrangements for the required terms and conditions do not currently meet the requirements of National Minimum Standards. Of those service user files examined at random, none contained a signed and individualised document setting out the terms and conditions, although a blank document was available. At a subsequent meeting to the inspection between the Registered Person, Registered Manager and CSCI, inspectors were advised that terms and conditions documents for each service user were being held separately within locked cabinets. Inspectors looked for documents at the time of inspection and expected terms and conditions to form part of the service users guide on the basis that the Care Homes Regulations 2001 require it (Regulation 5(1)(b)), however, it is accepted that this requirement is not clearly stated within the National Minimum Standards document for care homes accommodating older people. Inspectors advised that any request to depart from a regulatory requirement must be put in writing to the CSCI detailing the reasons for the request and why such a departure would benefit service users. Arrangements for the admission of two service users that had come to live at the home were reviewed. Pre-admission assessments were complete and although the information available to the home was brief, there was no apparent follow-up to ascertain the broader needs of the individual. It is important to ensure that any pre-admission diagnosis or care requirement is fully translated into a clear decision and plan for the individual, having undertaken a full consultation process. The Registered Person will need to ensure that the assessment tools used to determine pre-decision planning are current and appropriate. An example is that assessment tools used to undertake particular mental frailty is recommended to be of the MMSE type. The Registered Person will need to ensure that service users are not admitted to the home for ‘Intermediate Care,’ as opposed to a respite break, as the service is not registered to provide this service. The service must ensure that an appropriate pre-admission assessment is undertaken to ensure that the care required during the period of residence is appropriate. The conclusion of this inspection is that a number of the arrangements and systems in operation were unable to evidence that that the service has full capacity to meet all service users’ needs. Although having improved since the previous inspection, the progress has been relatively slow. It is accepted and acknowledged that the service has achieved a higher degree of compliance since the previous inspection. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 10 It is of concern that a number of service users accommodated were showing a need for care related to increasing mental frailty. Discussion was undertaken between Inspectors and the Manager for a need to undertake an assessment of those service users within this descriptive group and to apply for a variation to the existing registration category to accommodate specific service users. See Staffing section. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 • • • Service users do not fully benefit from the plan of care or fully adequate healthcare practices. Prescribed medicine practices were satisfactory. The outcome of privacy and dignity for service users was maintained. Arrangements for end of life issues and illness were not fully developed. EVIDENCE: A case tracking approach was used to examine the way in which the service manages the care planning process for service users. Six plans were sampled at random. Three of the plans were in relation to service users that had joined the home recently. It was disappointing to note that limited progress had been made since the previous inspection. The plans, overall, would benefit from a development of a ‘person centred’ approach. This would enable greater emphasis upon maintaining strengths and interests and desired outcomes from the service user’s perspective rather than addressing perceived needs, although this latter point must continue to be included within the plan. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 12 Life histories were included in plans, which indicates that effort has been made to understand relevant historical matters although more recent factors could have formed a more influential part of the current plan for some service users. Some of the assessed needs identified as part of the single assessment/care management approach were not carried forward to the service plans for some individuals. One example, relating to a person recently admitted from a healthcare setting, identified one need, relating to short-term memory loss, although it was clear upon meeting the individual that they had complex physical and emotional healthcare, and personal needs, requirements. These needs were not adequately planned for in view of the length of time the person had been accommodated. None of the care plans sampled provided a clear indication that the person was integral to the decision making process or engaged in any meaningful way with construction of the care plan. Where a lack of capacity to contribute is considered, the method and process must form part of the care plan. Overall there is a lack of attention to detail. Inspectors were of the view that more senior staff are required to be trained to ensure this aspect of the home’s service is improved. Care plans must contain elements of meaningful decision making and method to ensure that carers who are required to undertake tasks are clear about when, why and how to assist and support service users. Care decisions were weak, with examples such as ‘Incontinent’, ‘needs reminding’ and ‘requires assistance’ being common. These are unhelpful in their subjectivity. Instructions to carers included; ‘take to toilet’, ‘assist’ and other similar instructions. To achieve consistency and appropriate support the methods need to be clear and less subjective. A further aspect of the care plans that had not developed since the previous inspection related to primary healthcare arrangements and monitoring. Brief records relating to healthcare appointments were found in daily records or in a record of healthcare appointment. This information was not related to the plan of care to ensure an approach of care continuity. Whilst the inspection was unable to determine that service users were not receiving appropriate healthcare, the way in which this is being managed is not reflective of sound practice. The care plan of one individual indicated that the person had undergone an operation, with a follow up appointment for sutures to be removed. The care plan did not reflect any post-operative care or track the progress of this requirement. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 13 Conditions, for which some individuals were being prescribed medicines, were not specifically included within the care plan, for example, where a persons legs are required to be elevated, suspected absences, and urinary problems. These matters need to be addressed within the plan in order for carers to be aware of the care needs for each individual. Care plans seen did indicate that that various risk assessments and scoring tools were being used. These included, for example, nutrition, mobility and pressure sore risk. This is a positive inclusion, although the results of these scores and assessments need to be translated into the care delivery in a way that staff can follow and understand. The presence of a risk assessment does not inform staff of what they are required to do. Staff were observed to be patient and supportive towards service users and, based upon the outcome of the previous inspection, this is a positive and welcome development. There remains, however, some further development to staff practice regarding moving and handling. Inspectors observed staff using potentially harmful techniques and this indicates both a training and supervisory requirement. The prescribed medicines administration was not fully reviewed on this occasion. The medicines were maintained in a secure environment and the daily records were sampled and found to be adequately recorded. Carers’ practice was observed at various points throughout the inspection and was found to be consistently maintained in a dignified way and with regard to the person’s privacy. This is notwithstanding the practices noted as part of moving and handling. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 14 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 & 15. Service users benefit from access to religious services and the opportunity to access local community or receive visitors. Some aspects to do with choice had developed. relating to nutrition need to improve. EVIDENCE: Since the previous inspection a positive development has taken place in the form of an activity co-ordinator who takes a lead in creating opportunities for more stimulation and a socially inclusive lifestyle for service users. Assessments had been undertaken and these were comprehensive, along with individual records, however, these were not linked to the main care plan and some thought needs to be undertaken as to how these might be integrated. Service users are supported to attend religious services if they require. Service users spoken with commented favourably on the work of the activity co-ordinator and this indicates the positive impact this has made on the home. Some recording practices Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 15 This inspection concluded that service users appeared more engaged with their environment and were more readily willing to communicate, which may indicate a shift in culture at the home. Some service users spoke enthusiastically about recent outings to the Castle Park and to a local garden centre. Relatives and friends spoken with confirmed that visiting was flexible and that they were positively greeted. Visited rooms indicated that service users had a choice of their environment, for example, their own furniture and personal items. Issues associated with consultation and autonomy had improved, with examples found of service users having options such as activities and menu planning. The Manager will need to develop this to ensure that all service users, regardless of needs and communication skills, have equal opportunities. Whilst the standard associated with menu planning was not fully inspected, it is acknowledged that the Manager had made some changes to menus, in consultation, and this included a wider choice of meals. The Manager must ensure that records relating to the amount of food intake by service users are promptly recorded. On the day on inspection the carer undertaking this task was completing the record some time after the meal and was relying upon recall and memory. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 16 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): 17 & 18 • • Service users’ legal rights are not fully protected. Service outcomes for the protection of vulnerable adults could be further developed. EVIDENCE: The Registered Person will need to ensure that matters associated with service users’ legal rights are addressed. This includes the introduction of terms and conditions that meet with National Minimum Standards and regulatory requirements and to ensure that arrangements are in place for those who lack capacity to give consent. The arrangements in place for the protection of service users from abuse are, on a day-to-day basis, adequate in terms of key policies. However, the inspection highlighted that some practices and developments potentially placed service users at some risk. Examples of this include the lack of training for staff on adult protection issues, key care practices and recruitment procedures. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26. • The environment was, on the whole, comfortable, warm and adequately decorated, however, there were some safety concerns. EVIDENCE: A programme of renewal and improvement is in place, although it was noted that whilst some improvements have been made since the previous inspection, the carpet in one bathroom, noted on previous inspections to require replacement, remains. Parts of the home were being redecorated. The grounds are well maintained, although the difficulty of a step from the home to the garden via exit doors remains. In order to comply with National Minimum Standard 19.4, a plan setting out the time scale for these improvements needs to be sent to the CSCI. The Inspector notes that a cupboard containing mains electrical switchgear was unlocked and may have posed a danger to service users. A notice stating Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 18 ‘danger 415 volts’ was attached to a light switch. The person registered was requested to check the validity of this sign with a qualified electrician. Subsequent to this inspection this had been done and confirmation received that it should remain and that there was no danger to service users. A number of towels for service user use were found to be very worn and frayed, clearly in need of replacement. In visiting communal bathrooms it was noted that ‘bar’ soap was in use. This has been raised on a number of occasions previously as being at higher risk of cross contamination. Service users should use their own toiletries and staff should use anti-bacterial liquid soap. Two communal toilets were noted to have no soap or towels present, posing a risk of cross contamination. The furniture and fittings were satisfactory and the home appeared clean with no unpleasant odours. The laundry arrangements were found to comply with requirements on this occasion. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 • • • The home is adequately staffed and the skill mix of staff is overall adequate, although there is a need for specific staff training. Service users do not benefit from adequate recruitment policies and procedures. The staff training and development programme needs further work to fully comply with requirements. EVIDENCE: The service uses a staff/service user ratio calculation method recommended by the Department of Health. This was inspected and the ratios were in accord with the staff roster. The home employs separate cleaning and catering staff. A total of 14 carers were employed. The Manager produced records to indicate the training staff were hoping to attend and the previous training they had attended. Apart from NVQ2 training (9 staff) the majority of training centred upon ‘statutory’ training such as moving and handling (12 staff) and food hygiene (4 staff). One record seen indicated that 1 carer had NVQ3, but a subsequently seen record indicated 5 had completed the training. The training and development approach would benefit from review to reflect best practice. An assessment of the training and development needs of the service, for example what experience, skills and knowledge do workers require Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 20 in order to provide the service set out within the Statement of Purpose. The approach should then identify what experience, skills and knowledge already exist, leaving the difference between these two factors as being the training and development plan. Individual training plans should reflect this and cross reference with the overall development strategy. A financial budget and timescale should be drawn together to facilitate this approach. As previously stated within this report, a number of service users present care needs associated with complex care strategies. Most staff employed do not have the skills and experience associated with this aspect of care requirement and as such the training strategy needs to reflect the acquisition of these skills. Staff recruitment was sampled using random staff files. These were compared with the regulatory requirements and found to be incomplete. The Manager is required to ensure that any short falls are corrected. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38. • • • • • • • The Manager has been deemed fit under the meaning of the Care Standards Act 2000. The management approach is developing to improve the outcomes for service users. The quality assurance and quality monitoring approach remains poor. Service users benefit from safe, adequate arrangements to safeguard personal monies. Supervision arrangements for staff are developing. Not all records held were being adequately maintained. Health and safety matters are in need of review. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 22 EVIDENCE: Since the previous inspection the Manager, Mrs Barlow, has applied to be registered and has now been deemed ‘fit to be registered’ and to manage the home. The information gathered in relation to this inspection, from various sources, indicates that the culture of the home is improving, with increased choices for service users and some aspects of the daily management improving. The quality assurance and quality monitoring system has not developed from the previous inspection and remains in need of attention to ensure that the care outcomes for service users is safe and appropriate. The home’s arrangement for the safeguard of personal monies deposited in safe custody was checked at random and found to be secure, accessible and adequately recorded. The service was unable to evidence that adequate induction systems were in place, although the supervision system, recently improved, had commenced and appeared able to meet the requirements of National Minimum Standards, providing the frequency of sessions is maintained. Not all records that are required to be maintained by regulation were adequate. Those records checked that did not comply with requirements included Statement of Purpose, Service Users Guide, record of persons employed, record of whether the staff roster actually worked and Regulation 26 monthly reports by the persons in control. Aspects of the home’s standards in relation to health and safety matters have been raised within this report. Whilst the overall home was adequate in terms of general safety, there are matters outstanding from previous reports that require attention. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 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 2 2 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 2 18 2 2 2 2 2 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 3 2 2 Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Timescale for action 4,5, & 6 The Registered Person must 30/04/06 develop a Service Users Guide that meets the requirements of Regulation. This is a repeat requirement. 5(1b) & 6 The Registered Person must set 30/04/06 out the terms and conditions as require by regulation. 4, 5, 12, The Registered Person must 30/04/06 14, 15, ensure that risk assessments associated with care plans are maintained. 4-6,8The Registered Person must 30/04/06 9,12ensure that the service is able to 19,23,24 demonstrate the capacity to meet the needs of service users. This is a repeat requirement. 12, 14, 15 The Registered Person must 30/04/06 ensure that service users’ health, personal and social care needs and aspirations are set out in an individual plan of care. This is a repeat requirement. 12,13 The Registered Person must 30/04/06 ensure that service users’ health is promoted. Regulation Requirement 2. 3 OP2 OP3 4 OP4 5 OP7 6 OP8 Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 25 7 OP11 8 OP15 9 OP17 10 OP18 11 OP19 12 OP20 13 OP21 14 OP22 15 OP29 16 OP30 12, 14, 15 The Registered Person must ensure that practices associated with illness and end of life matters are integral to the care planning process. 17 The Registered Person must ensure that the home can demonstrate that wholesome nutritious food, in adequate quantities, is provided at all times. This is a repeat requirement. 15 The Registered Person must ensure that service users’ legal rights are protected by ensuring they facilitate advocacy services where the person lacks capacity. 13 The Registered Person must ensure that service users are protected from abuse. This is a repeat requirement. 23,24 The Registered Person must ensure that service users live in a safe, well maintained environment. This is a repeat requirement. 23,24 The Registered Person must ensure that service users have access to safe communal outdoor facilities. 15,23,24 The Registered Person must ensure that service users have sufficient and suitable washing facilities. This is a repeat requirement. 23 The Registered Person must ensure that an assessment of the premises has been undertaken. 18,19,24 The Registered Person must ensure that service users are protected by the home’s recruitment policy and practices. This is a repeat requirement. 18 The Registered Person must ensure that staff are all trained and competent to do their jobs. DS0000053190.V279993.R01.S.doc 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 Stanway Green Lodge Version 5.1 Page 26 17 OP33 24 18 OP37 17 19 OP38 13,16,23, 24 The Registered Person must 30/04/06 ensure that the service is subject to a quality assurance and quality monitoring system based upon the consultation with service users. The Registered Person must 30/04/06 ensure that records required by regulation are appropriately maintained. This is a repeat requirement. The Registered Person must 30/04/06 ensure that the health, safety and welfare of service users and staff are promoted and protected. This is a repeat requirement. 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 OP1 Good Practice Recommendations It is recommended the Registered Person further develops the Statement of Purpose to give a broader range of information. Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Stanway Green Lodge DS0000053190.V279993.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!