Inspection on 27/09/07 for Stanwell Rest Home

This inspection was carried out on 27th September 2007.

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

Stanwell Rest Home 25/03/08

Stanwell Rest Home 18/04/07

Stanwell Rest Home 31/08/06

Stanwell Rest Home 25/01/06

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 Mrs Michelle Presdee Unannounced Inspection 09:30 27 September 2007 th 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.V344321.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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.V344321.R01.S.doc Version 5.2 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 stanwellcarehome@btinternet.com 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.V344321.R01.S.doc Version 5.2 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. 18th April 2007 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 can 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 who only require assistance with personal care needs can be accommodated in self-contained apartments situated at the rear of the main property. The fees for the home range from £333.00 to £445.00. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection the Acting manager and Proprietor assisted the inspector. A tour of all parts of the home was undertaken. Some staff and residents and three visitors on the day were spoken with. Seven service user surveys, five staff surveys, one care manager survey, four health surveys and eight relative carers and advocate surveys were received. The majority of the comments received were of a positive nature and included “staff work hard”, “staff are always polite and friendly” and “the care is excellent”. Some had made some negative comments amongst the positive including, “two staff members on duty between 8 and 9 at night, which is not satisfactory”. “Toilet/bathrooms can be very messy/smelly be evening”. Mr Conway explained the plan in the near future is for the current registered manager to relinquish her current registration and take up another post in the home and for the acting manager to apply to become the registered manager. The acting manager has previously been registered and explained she is looking forward to working in the home. Staff spoken to felt positive about the new acting manager stating she, in the two weeks she had been in the home was open to listening and trying new things. What the service does well: What has improved since the last inspection? The provider has made some progress in dealing with five previous requirements. Two training sessions on abuse have taken place and a further one has been booked to ensure all staff have received training. Quality audit has taken place with changes made in the home as a result of this. Improvements are due to be made to the environment including signage, new Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 6 carpets in all communal areas and the communal areas being painted. Window restrictors have been placed on the majority of windows. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 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.V344321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Assessments do not identify a service users needs prior to admission or reflect the current situation, which does not ensure the home can meet their needs. EVIDENCE: The assessments of two residents in the flats were looked at. One resident was spoken with and two members of her family. It was not possible to establish from assessments seen a pre admission assessment had been completed before the resident moved into the home. It was clear from these discussions her needs had changed since she came into the home. It was also clear from discussions with staff members the needs of other residents in the flats had changed and at the present time and they were more complex, which was not reflected in the assessment. The assessments on file were the same as when the residents had first come into the home and did not reflect the current Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 9 situation. The assessment and care plan is covered in thirteen different sections, and one staff member explained it is time consuming to read and not always a useful document. Care staff and the acting manager did state the whole process of assessment and care plan is being reviewed and a new system is being devised. The home does not provide intermediate care. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans do not give adequate detailed information to ensure care staff have sufficient detail to meet a service users needs. Risk assessments must reflect the current risk and say how the risk can be minimised. Health needs are met in the home by a range of services. The medication procedures involving the dispensing, administration and recording do not ensure service users safety. Service users are treated in a dignified manner and their right to privacy is upheld. EVIDENCE: The plan of care for the two service users whose assessments were seen were also viewed; discussion with residents, visitors and staff also helped to form the judgements on service user plans. It was clear care plans were not up to date and did not contain detailed information to inform care workers how to care for residents. Examples included one care plan stating the resident had a good appetite but it was clear from discussions this situation had changed and there was concerns regarding the food intake of this resident, which could Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 11 easily be missed by care staff leading to concerns over the nutrition intake of this resident. One resident smoked but the care plan did not reflect the current situation, which had recently changed making sure the resident was always supervised when she smoked. Care plans did not include a recent nutritional assessment. Risk assessments had not been undertaken for these two residents despite there being considerable risks for the residents. Care plans need to detail what care is required and how this should be provided. Care plans are not being reviewed on a monthly basis and it was agreed they would be. The acting manager and staff spoken to were aware care plans needed to change and the acting manager was currently devising a new system. Care plans did include details of all visits by health professionals. Mr Conway advised the inspector the home has good relationships with health professionals in the area and health professionals will always visit on request. The home will assist residents to hospital appointments. Four health surveys were received and comments included “They have a caring and compassionate attitude towards their inmates” and “I have never been concerned by the standard of care”. Whilst in the flats one member of staff was dispensing and administering medication. The inspector observed and then discussed with the member of staff. No medication procedure is available in the flats. The member of staff explained the way she was administering the medication was the way she had been taught by a more senior member of staff. This involved dispensing medication from the monitored dosage sheets into pots for each resident. Each pot is then taken to each resident and they are watched whist they take the medication. When all residents have taken their medication the medical administration records are signed. When discussed with the member of staff they were able to see the risks this could pose. When looking at the medical administration records it was noted on the previous night and in the morning one resident’s records had not been signed despite the medication being administered. The medication administration records were not clear as they had incorrect dates, for example for the week beginning the 24th the dates started with the 20th; staff had changed some dated whilst others had not so the order went 20, 21, 22, 23, 28, 29, 30. No residents in the home are self-medicating. When looking around the home it was noted many residents have prescribed creams in their rooms. When looking at these it was noted many of these were out of date, some by three years. It was agreed all creams, which were out of date would be thrown away and all other creams would be kept in locked draws or bathroom cabinets. From observations on the day and from discussions with residents, staff and visitors it was clear residents were treated in a dignified manner and in a way, which respected their privacy. Visitors spoken to felt staff cared for their relatives in an excellent manner. Observations of staff working in the flats showed they had a respect for residents and always respected their privacy. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 12 Stanwell Rest Home DS0000012167.V344321.R01.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of social activities to meet service users needs. Residents are able to exercise choice and make decisions about their lives. Visitors are made welcome to the home and they can see service users in private. A rotating menu was available, but a choice was not always available at lunchtime for all residents. EVIDENCE: The home has recently employed activities co-ordinator as a result of the survey completed on November 2006. The inspector met the activities coordinator who was very enthusiastic about her job and was looking forward to providing both joint and individual activities. On the day of the inspection some friends of the church had been in to see residents. Arrangements are being made for some residents to attend church. Various religious services are offered in the home. One relative spoken to was concerned his relative did not seem to do anything. The activities co-ordinator explained some things the resident had been involved in recently. Discussions were held on including details of all activities offered on a weekly basis on a notice board in the home and in care plans. From records in care plans, which were not up to date it suggested residents had not been involved in social activities for 6 months. Mr Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 14 Conway advised some residents are taken out on a weekly basis in the home’s mini bus. An outsider entertainer calls in on a monthly basis and games take place on daily basis. Residents are offered manicures and a hairdresser calls in on a weekly basis. The activities co-ordinator explained she was going to arrange a trip to the theatre after talking to some residents. Visitors can call into the home at any time and visitors on the day stated they were always made welcome. One visitor stated she felt the “staff were excellent” and was pleased she could see her relative both in private and in the communal areas. It was clear from observations on the day residents are offered choices in their daily living activities. When over in the flats one resident was still in her sleep wear, which was her choice. Some residents were with their visitors whilst other residents spent time in their rooms. One resident had gone out of the home on their own. Breakfast was served at a time suitable to the residents. The inspector was advised residents could go to bed when they want, but most prefer to go earlier rather than later. The home has a rotating menu. A choice is available at breakfast time and in the evening. At lunchtime only one choice is offered in the front building. The cook advised the inspector if they are aware the resident does not like the lunchtime meal an alternative will be provided. This was in contrast to the residents in the flats who at lunchtime have a choice of ordering meals from an outside company. Meals are delivered cold and plated and then warmed up in the microwave in resident’s room. It was not clear why the residents are offered this choice but the residents in the front house are not. When meals are delivered the temperature should be recorded, the temperature of the fridge where the food is stored should be recorded and the temperature of the food when served should be recorded. Most meals are cooked from frozen with fresh vegetables served at the weekend. A menu is not currently displayed in the home. Two residents spoken to stated the meals were “ok.” Stanwell Rest Home DS0000012167.V344321.R01.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives receive adequate information to enable them to make a complaint. Service users are protected from abuse and staff have received training in this area. EVIDENCE: The home has a complaints procedure, which details all the necessary information, including names, addresses, telephone numbers and timescales. A copy is given to all residents and their next of kin. A copy of the complaints procedure is displayed in the home. The home keeps a log of all complaints. Two complaints were recorded in the book, which had been dealt with. The Commission has received no complaints since the last inspection. Visitors stated they would know how and who to complain to. Residents meetings are held on a regular basis and try to establish if residents are unhappy with any issues. Two training sessions provided by outside trainers on abuse have taken place and one more has been booked to ensure all staff undertakes training in this area. Care staff had knowledge of the different types of abuse and what to do if abuse was suspected in the home. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 16 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): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a mainly clean and comfortable environment for the enjoyment of service users. EVIDENCE: A tour of all parts of the home was undertaken. The home was clean and no unpleasant odours were detected. The environment in the flats provides eight spacious rooms, which provide a kitchen area come lounge/ diner and a separate bedroom. All eight flats have en-suite shower rooms. All rooms had window restrictors except one large velux window on the first floor in the corridor. In the front building nine bedrooms were randomly looked at with various bathrooms and various lounge/dining rooms .It was noted furniture including a wardrobe, a buggy and a tripod were stored next to the fire exit door. It was agreed these should be removed. The water was tested in various Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 17 sinks in bedrooms and found to be too hot to touch. Signs were put over the sinks saying caution water hot but this is not an adequate precaution for residents who have dementia. The water in the baths was a good temperature and thermometers were evident to test the bath water temperature. Rooms seen were clean and some had been personalised by residents. The environment is due to be improved to meet the needs of the residents in the home. Photographs of each resident have been put on the front of each bedroom door. Mr Conway explained some money has been obtained from a government grant, which is going to be used to improve the environment for resident’s including signage, carpets and painting in the home. Mr Conway has received quotes for changing the carpets, to carpets which have a plain weave in the communal areas of the home and quotes for painting all communal areas; working on colour coding. No dates have been confirmed yet. It was noted in each lounge a blackboard was present, the only information stored related to the day of the week. It was agreed it would be good to record the day, date, year, season and weather, which could be done with the residents. Concern was also expressed over the possibility of residents getting out of the front door of the flats. It would be possible for residents to walk from the front of the home through the garden and into the flats and out of the front door. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels do not meet the resident’s needs at all times. Training in the core areas has not been arranged to ensure staff members have the knowledge and skills to care for the residents. Good recruitment procedures offer protection for service users. EVIDENCE: The home employs twenty-six care staff. The home tries to employ five care staff in the morning, three in the afternoon and two night staff in the front building of the home. A cook works in the home 7days a week and a cleaner works in the home seven days a week. In the flats the home tries to have two carers on in the morning, one in the afternoon and one at night working an awake shift. From discussion with staff it was clear they felt at the current time two members of staff were needed to work in the flats in the morning shift. One member of staff explained she had recently covered some of the morning shifts on her own and she felt there had been an incident, which had left a resident at risk. From observations on the day it was clear at that time two members of staff were needed in the flats on the morning shift. From the duty rota seen for the week prior to the inspection, it was noted only one member of staff had worked in the flats, the member of staff had worked both 12-hour shifts on consecutive days. Staff felt on most of the other shifts staffing levels were adequate to meet the need of residents. The one time that was Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 19 mentioned was having an extra member of staff later in the evening, as only two members of staff are on duty in the front buildings from 8 o’clock. One relative survey had mentioned at that time there was not enough staff and the toilets are smelly. As well as care staff Mr Conway explained he is in the home most days, the acting manager works 40 hours a week, the activities coordinator works 20 hours and a director of the company works ten hours a week and an administrator works 35 hours a week. Comments on staff in the home from surveys and from two visitors were very positive. They included “we find staff very friendly and helpful”, “the carers are most attentive and friendly”. The inspector was informed well over 50 of staff have achieved a National Vocational Qualification Level 2. Staff who have worked in the home over six weeks will be considered to be put forward to achieve this qualification. The staff records of four members of staff were looked at including staff that had recently started work in the home. The staffing records were well organised and it was possible to establish all necessary checks had been completed. Two written references were available for each member of staff. It was noted for one member of staff the reference did not give any information so it was agreed another reference would be sent for. In another staff file it was noted the member of staff had been off on extended leave for over six months. All staff files contained an application form and photographic identification. The inspector was advised training records were maintained on staff files. However when looking at six staff files it was not possible to establish that all staff had current in date training in moving and handling, infection control, first aid or basic food hygiene. A training programme was shown to the inspector, which included skincare, dementia, palliative care, medications, abuse and protection of vulnerable adults and nutrition. However this had not been recorded on staff files. For one member of staff who had worked in the home over a year the only training recorded was fire training and for another member of staff the last moving and handling training was in May 2005. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. An experienced manager runs the home, although there are deficiencies in management systems. The finances of resident’s personal allowance are well managed. Staff do not currently receive adequate supervision sessions to support them in their work. Health and safety issues are not always promoted in the home, which could leave service users at risk . EVIDENCE: The inspector was advised the current manager has been on and off sick leave for the last three months and the deputy manager left giving one days notice. The current acting manager has only been in post for two weeks. From Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 21 discussions with the acting manager who has previously been a registered manager, it was clear she had many ideas to change practices in the home and had an awareness of things, which were currently wrong. Staff spoken to were very supportive of the new acting manager stating she was very approachable and had already listened to them. The acting manager stated so far she had had the full support of Mr Conway. It was clear from discussions with staff and from observations on the day the home tries to run in a way, which is flexible, and support the routines of residents rather than the home. A quality audit was undertaken in November 2006 and sought the views of residents and visitors, the majority of feedback was good, with activities being the common trend, which needed to improve. Another quality audit is due to take place in November2007. However other issues regarding assessments, care plans, medication procedures, environment, staffing levels at certain times, training and health and safety must be improved to ensure the home is well managed and run in the best interest of the residents. The home manages the personal allowance for most residents in the home. The inspector looked at the storage, recording and accuracy of this and found all to be correct. Records were maintained of all monies in and out, with receipts maintained and a running total kept, which matched the amount of money held. One resident went shopping on the day of the inspection and she requested and was given some of her personal allowance to spend, which was recorded. When looking in staff files it was clear care staff had not received sufficient supervision session. Mr Conway explained whilst the manager has been off supervision had not taken place. Staff spoken to stated they did not receive regular supervision. The new acting manager has already started supervision sessions with staff members. When looking around the home it was clear the health and safety practices need to be improved. In the flats it was noticed the laundry door was open and cleaning fluids were left out. The fire exit in the end of the front building was not clear. One large window was not fitted with a window restrictor. The temperatures in the fridges in the flats were not consistently being recorded. Meal choices were not being recorded. The temperature of the water in the sinks in some areas of the home was too hot. Risk assessments need to be carried out where necessary on individuals and on parts of the environment. The accident book was being completed but all entries were left in the accident book, entries were not numbered and no analysis was taking place. The acting manager did state she was going to change this practice. The fire log had recordings to show all necessary checks were being carried out in the agreed timescales and staff were receiving training in fire issues. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 X 1 Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement Pre admission assessments must be completed giving a detailed account of all a residents needs. Assessments must be reviewed and kept up-to-date. Service user plans must be kept up-to-date and provide detailed action to be taken by carers to meet service users needs. Plans must look at the holistic needs of people including nutritional assessments. This requirement is repeated from inspection 18/4/07. To safeguard the people who use the service from potential risk of harm they all must have an individual and full risk assessment detailing the specific risk to the residents and clearly states how the risk will be minimised. Timescale for action 30/11/07 2. OP7 15 30/11/07 3 OP7 13 (4) 30/11/07 4 OP9 13 (2) This requirement has been repeated from inspection dated 31/8/06. Medication procedures must be 30/11/07 followed ensuring the dispensing, DS0000012167.V344321.R01.S.doc Version 5.2 Page 24 Stanwell Rest Home 5 OP19 23 administration and recording of medication is correct to keep residents safe. All prescribed creams must be kept in a locked cabinet. All out of date creams must be thrown away. The deficiencies in the environment including the carpets, signage and painting must be completed. This is a repeated requirement from inspection dated 31.8.06. All windows must be risk assessed and restrictors fitted where necessary. This is a repeated requirement from inspection dated 31/08/06. The fire exit must be kept clear. All hot water outlets must be tested and adequate steps must be taken to protect residents from scalding. 30/11/07 6 7 OP27 OP30 18 18 Staffing levels must ensure at all times all the needs of the residents can be met. Staff must receive training in the key areas of first aid, infection control, moving and handling and basic food hygiene and records must be available. The management of the home needs to improve to ensure all repeated requirements and new requirements are met within the timescales. All COSHH substances must be safely locked away after use at all times. DS0000012167.V344321.R01.S.doc 30/11/07 30/12/07 8 OP31 9 30/12/07 9 OP38 13 30/11/07 Stanwell Rest Home Version 5.2 Page 25 This requirement has been repeated from the last inspection dated 31/08/06. 10 OP36 18 Staff must receive a minimum of six supervision sessions in a twelve- month period. 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations All residents should be given a choice at lunchtime. Stanwell Rest Home DS0000012167.V344321.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Stanwell Rest Home DS0000012167.V344321.R01.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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