Inspection on 25/01/06 for Stanwell Rest Home

This inspection was carried out on 25th 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 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

Stanwell Rest Home 25/03/08

Stanwell Rest Home 27/09/07

Stanwell Rest Home 18/04/07

Stanwell Rest Home 31/08/06

Stanwell Rest Home 26/01/05

Stanwell Rest Home 07/07/04

Stanwell Rest Home 09/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Stanwell Rest Home 72/76 Shirley Avenue Southampton Hampshire SO15 5NJ Lead Inspector Chris Johnson Unannounced Inspection 25th January 2006 09:15 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 Stanwell Rest Home DS0000012167.V252103.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. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stanwell Rest Home Address 72/76 Shirley Avenue Southampton Hampshire SO15 5NJ 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) 023 8077 5942 Stanwell Rest Home Limited Mrs Margaret Haug Care Home 34 Category(ies) of Dementia - over 65 years of age (26), Mental registration, with number disorder, excluding learning disability or of places dementia (26), Mental Disorder, excluding learning disability or dementia - over 65 years of age (26), Old age, not falling within any other category (34) Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users in category MD not to be admitted under 55 years of age. The eight service users to be accommodated in the separate apartments must be in the category of OP and in need of personal care only. The apartments may only be used by service users whose assessed needs can be met within that environment. 21st June 2005 Date of last inspection Brief Description of the Service: Stanwell Rest Home is a care home that is registered to provide personal care and accommodation for a maximum of thirty-four older people. The home is situated in a residential area of Southampton close to Shirley shopping centre and within easy access of public transport. Accommodation is split between two buildings. Twenty-six residents may be accommodated within the main building. This building consists of three former residential properties that are linked internally. Accommodation is spread over two floors. Eight further residents whom only require assistance with personal care needs can be accommodated in self-contained apartments situated at the rear of the main property. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection carried out for the year April 2005/06. This inspection was unannounced and took place on the 25th January 2006. The purpose of this visit was to carry out an inspection of the home and follow up on requirements made at the last inspection. Both reports should be read for an overview of how the home is meeting the standards. The findings of this report are based on a number of different sources of evidence including; a tour of the premises that included looking at service user’s bedrooms and communal areas. Staff and care records were inspected; several staff and residents were spoken with. Written and verbal feedback was given to the provider and manager the day following the inspection. Several immediate requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements are needed in the assessment process to reduce the danger of someone moving into the home whose needs cannot be met. More regular reviews of residents’ care needs must be implemented to ensure that care needs are not overlooked. A big improvement is required in the level of written information available to staff regarding the help, and level of assistance that people need. Recruitment procedures need to be more robust to ensure that residents are not potentially put at risk. Whilst the home is generally safe Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 6 improvements are needed to ensure that doors intended to offer protection from smoke and or fire are not propped open. 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. Stanwell Rest Home DS0000012167.V252103.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 Stanwell Rest Home DS0000012167.V252103.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): 3, 4 and 6 The assessment process is poor and does not ensure that the needs of prospective residents will be met within the home. EVIDENCE: Stanwell does not provide intermediate care. This standard is therefore not applicable and was not assessed. Pre admission assessment and care notes were looked at for several residents. Assessments had not been completed prior to some residents being admitted to the home. No documentation was available to demonstrate that these had been done. Others were undated and it was not therefore possible to ascertain at what point in the admission process they had been completed. Concern was raised regarding the lack of assessment documentation in respect of two respite residents. The home could not demonstrate that the needs of either resident were being met. A resident accommodated within the flats was very confused. Discussion with staff and observation would suggest that his needs were greater than those stated in the conditions of registration for the flats and that the person needed to be accommodated within the main building with appropriate support. This Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 9 highlights the need to ensure that thorough assessments are undertaken prior to admission. The manager had not undertaken an assessment for another resident. The provider and manager stated that the person had been admitted as an emergency admission and that they had only believed that the person was coming to visit the home. However written records and discussion with the care manager would suggest that the manager had allowed the person to stay and had not contacted the care manager to inform her of this arrangement or carried out an assessment. In addition to this a care plan was not in place for this resident despite them having been at the home for ten days and that they had high needs with regard to the management of diabetes. During the inspection the resident became unwell and was found to be using another residents bed to rest. In discussion with staff the inspector was informed that the person had become unwell due to their diabetes and that it had been advised that they should rest in a downstairs room. However due to the lack of a care plan or assessment staff did not seem clear as to the persons care needs. Residents told the inspector that they considered that their care needs’ were being met at the home. One resident commented that they had only been able to reach the level of independence that they now enjoyed due to the care and help that they had received. However this is clearly not the experience of all residents. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 10 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 and 10 An improvement is needed in the written information available to staff regarding residents care needs as currently some specific care needs are being overlooked. EVIDENCE: Whilst most residents had a written care plan, a care plan was not in place for a resident admitted as respite on 16/01/06. Neither was there any written guidance as to their needs despite them needing assistance with the management of diabetes. Care plans for several other residents were looked at and found to be lacking in detail. Care plans need to be more specific especially regarding personal care needs and those associated with mental health. Several of the care plans looked at had not been reviewed on a regular basis which presents a risk that changes in care needs may not be addressed. Staff confirmed that they had access to care plans and from discussion were aware of most individuals support needs. However this could only be substantiated verbally and there is a danger that things will be missed if they are not recorded accurately. Another plan contained out of date information, Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 11 which again could be misleading. Residents told the inspector that they had access to healthcare as necessary and records substantiated this. Staff were not however clear regarding the health care needs of the resident referred to previously and the management of the this persons healthcare need’s in respect of diabetes was poor. Blood sugar readings had not been recorded for the day that they had become unwell and there was insufficient evidence to demonstrate that appropriate action had been taken when fluctuations in readings had occurred. Residents told the inspector that staff respected their privacy. This was supported by the guidance in care plans, the use of screens in shared rooms, door locks and observations during the inspection. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 12 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 and 15 Residents receive a healthy and wholesome diet. EVIDENCE: A requirement had been made at the last inspection that the home provided transport in line with the Statement of Purpose. The home now has a new mini bus and residents confirmed that they had been able to go out in it for trips and to access the community. Residents said that they were free to choose how to spend their day and to choose whether or not to engage in an activity. Residents confirmed that there were not any restrictions placed on them regarding times for getting and going to bed. In discussion with one resident they commented that they liked the fact that they could stay in bed to a time that they preferred and come down for breakfast at any time. All residents spoken with were happy with the standard and quantity of food available. Comments included, “The food is very good”, “ It is excellent, I have breakfast in bed and you can have as much as you want” and “ It is good”. The home employs a cook and good standards of food hygiene were being followed and the cook had recently undertaken a food hygiene course. Records are maintained of all food provided and these demonstrated that residents are provided with a healthy and wholesome diet. The inspector did advise that menus could be put on display to enable residents to know in advance what choices were available on a given day. It was also advised that Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 13 the cook take over the recording and monitoring of fridge temperatures to ensure consistency. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: Standards 16, 17 and 18 were assessed at the last inspection and on that occasion found to be satisfactory. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 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): 19,24 and 26 Residents live in a clean, well-maintained environment that meets most of their needs. EVIDENCE: The home was clean and well kept throughout and is homely in appearance. Repair and redecoration are carried out as needed. A maintenance person is employed and was on site during the inspection. The garden is safe and secure and very well maintained. All residents spoken with were in agreement that good standards of hygiene were maintained. Policies and procedures were in place for the control of infection. Staff were observed to follow infection control procedures such as, using gloves and aprons and ample supplies of these were available. Call bells were fitted in all bedrooms seen. Residents reported that staff responded to call bells promptly. Bedrooms were inspected in depth at the last inspection and on that occasion found to be satisfactory. It was noticed however during this inspection that several residents did not have access to individual lockable storage within their rooms. This was discussed with the manager and provider and a requirement was made. From discussion with Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 16 some of the residents living in the flats it was found that not all residents had keys to the main entrance. This would appear to be an oversight as there were no recorded reasons or any identified risks as to why they could not hold their own key. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 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): 29 and 30 The level of training and support given to staff is adequate. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: The files of three members of staff employed since the last inspection were inspected and found to be lacking. Insufficient checks had been completed prior to them commencing working at the home. Protection of Vulnerable Adults checks were not confirmed until two of them had been in post for two months. The third member of staff had been in post for nearly three weeks before confirmation had been received. Whilst it was accepted that Criminal Records Bureau checks can take a while to be processed and returned evidence from files showed that these were not being requested until several weeks following commencement of employment. Staff retention is good and a number of members of staff have worked at the home for several years. This helps to provide stability and consistency to residents. Staff receive regular training and nearly half of the care staff have completed an NVQ qualification. Feedback from residents was that staff were very good and from observation of and discussion with staff the inspector noted them to be caring, hard working and thoughtful and respectful of residents needs. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 18 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, 35 and 38 Generally the home is safe and well managed. An improvement is however needed to ensure that all safety procedures are followed. EVIDENCE: Requirements from the previous inspection had been met within the agreed timescale. The provider is regularly in the home and provides support to the manager. Whilst the home is in the main well managed the manager does need to ensure that staff are regularly completing and updating care plans and must ensure that thorough assessments are carried out and is advised to ensure that she keeps up to date with changes to legislation. The home does manage and look after several residents’ money. This was found to be stored safely. Checks were made of several balances and all were correct and had been properly receipted and recorded. The home is generally safe. The only exception to this was that one bedroom door was being held open by a cord and a second bedroom door was wedged Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 19 open with a chair. These doors are intended to offer protection to residents in the event of a fire and should not therefore be held open by such means. All other areas of the home appeared to be safe and from inspection of the fire log book regular and thorough testing of the homes fire detection equipment had taken place. Certificates were available to demonstrate that equipment and aids used in the home are regularly serviced and tested. Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 20 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 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X 2 X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 21 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 OP3 Regulation 14 (1) Requirement Full assessments must be completed prior to admitting service users and records are to be kept of these. Timescale for action 27/01/06 2 OP3 14 (1) 3 OP4 12 (1) That care management 26/02/06 assessments are obtained prior to admission for any resident who is fully or partially funded. A review of the needs of the 27/01/06 resident discussed at the inspection must be carried out. Action is to be taken accordingly. All care plans must be reviewed and all care needs must be included. A care plan must be put in place for the resident identified during the inspection. All service users must be provided with lockable storage facilities in their rooms. Staff must not commence work at the home until all satisfactory checks have been made. Staff may only work in the home in line with the provisions of The DS0000012167.V252103.R01.S.doc 4 5 OP7 15 (2) (b) (c) 15 (1) 26/03/06 27/01/06 6 7 OP24 OP29 23(2)(m) 19 27/03/06 27/01/06 Stanwell Rest Home Version 5.1 Page 22 8 OP38 13 (4) Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. Bedroom doors and other designated fire doors must not be wedged or held open. You should consult with the Fire Authority regarding the most appropriate method of maintaining safety and take action accordingly. 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Stanwell Rest Home DS0000012167.V252103.R01.S.doc Version 5.1 Page 24 - 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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