Inspection on 28/02/07 for Stennards (Kn)

This inspection was carried out on 28th February 2007.

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

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

Other inspections for this house

Stennards (Kn) 13/11/08

Stennards (Kn) 20/02/06

Stennards (Kn) 20/10/05

Stennards (Kn) 15/03/05

Stennards (Kn) 14/07/04

Stennards (Kn) 08/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Stennards (Kn) 150-152 Middleton Hall Rd Kings Norton Birmingham West Midlands B30 1DN Lead Inspector Brenda O’Neill Key Unannounced Inspection 28th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stennards (Kn) DS0000016786.V328236.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. Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stennards (Kn) Address 150-152 Middleton Hall Rd Kings Norton Birmingham West Midlands B30 1DN 0121 458 3311 0121 459 0467 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 Dawn Lee-Harris Mr Peter David Lee-Harris Miss Philomena Mary Malanaphy Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one named person, who is diagnosed as having Dementia at the time of admission can be accommodated and cared for in this Home. 20th February 2006 Date of last inspection Brief Description of the Service: Stennards Kings Norton is located on Middleton Hall Road which is a mainly residential area. The home is close to both the shopping centres of Cotteridge and Northfield where there are various local amenities available. The home has easy access to local bus and train services. Formerly two separate houses the property has been converted and extended to offer care and accommodation to 25 older people. Accommodation is offered over two floors and comprises of nineteen single and three double bedrooms some of which have en-suite facilities. There is a shaft lift and stair lift for ease of access to the first floor. The home has two interconnecting lounges, a large dining room and a conservatory all located on the ground floor. One of the lounges and the conservatory overlook the large, well maintained rear garden. Also located on the ground floor is the kitchen, laundry, office and staff room. Throughout the home there are three bath/shower rooms two of which allow for staff assistance. There are numerous toilets located within close proximity of the communal areas and the bedrooms. The home aims to provide residents with the opportunity to participate in a variety of leisure activities both within and outside of the home such as music, progressive mobility, reminiscence and trips out to a church centre once a week with transport provided by ring and ride. At the time of this inspection fees at the home ranged from £314.00 to £346.00 per week plus a £15.00 per week top up fee. Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key inspection over one day in February 2007. During the course of the inspection a tour of the premises was carried out, three resident and two staff files were sampled as well as other care and health and safety records. The inspector spoke with the acting manager, the proprietor, briefly to one staff member, one visitor and five residents. Prior to the inspection the acting manager had returned a completed pre inspection questionnaire which gave some additional information about the home. The home had not received any complaints since the last inspection and none had been lodged with the Commission. What the service does well: This home has, over many years, consistently offered residents a very good level of service and this is reflected in the observations made during the course of the inspection and the comments on the questionnaires that had been completed by the relatives of some of the residents and the residents themselves. These were sampled and included the following comments: ‘ The quality of care my mother has received whilst at Stennards is excellent.’ ‘I cannot fault the quality of the service at all.’ ‘Very pleasant staff, good food, overall very pleased.’ ‘Attentive and kindly.’ ‘Very kind to me and friendly. I feel safe and like the company.’ ‘Good care, friendly atmosphere.’ The inspector spoke with one visitor who described the home as ‘very nice, very homely’ and stated he was always made welcome when he visited. He also said he ‘felt as if he had known the proprietors for years’. Care plans were well detailed and ensured staff knew the needs of the residents and what assistance they required. The daily records evidenced that any health care needs were identified by staff, followed up and monitored. Residents received any necessary input from health care professionals. The system in place for administering medication was well managed and ensured residents received their prescribed medication. There were no rigid rules in the home and routines were kept to a minimum. Residents were encouraged to exercise choice and control over their lives. Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 6 The menus at the home were varied and nutritious and residents had choices at all meal times. Residents were clearly enjoying their food at the time of the inspection. The home had a very stable staff team which was good for the continuity of care of the residents. Staff received regular ongoing training in a variety of topics to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. The home was well managed and the proprietors were frequent visitors and very pro active in overseeing the management of the home. The home offered residents a safe and comfortable environment where health and safety were well managed. What has improved since the last inspection? What they could do better: To show that the residents needs are being met the daily records need to be further developed to include evidence of their general well being, the care being offered/given and activities they have been involved in or refused. To further enhance the safety of the residents all manual handling risk assessments that detail the use of a hoist must detail the sling size and also any additional handling needs. To ensure the residents are safeguarded a POVA first check must be undertaken for staff prior to them commencing their employment. To ensure new staff are equipped with all the necessary skills and knowledge to be able to care for the residents they must have induction training in line with the specifications laid down by Skills for Care. Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 7 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. Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. The assessment procedures in the home are good and ensure staff know the needs of the residents prior to admission. EVIDENCE: The files for three residents admitted since the last inspection were sampled. All the files included copies of the assessments undertaken by the social workers involved in the admissions. The home also completed their own assessments on the preview visit day to the home. The home also completed booklets entitled ‘Assessment for good care planning’ which included a profile of the resident giving staff some information about the individuals’ past and family. Stennards (Kn) DS0000016786.V328236.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for care planning and undertaking risk assessments in the home are comprehensive and ensure staff know how to meet the needs of the residents and how to minimise any identified risks. The medication administration system is well managed and ensures the residents are not put at risk. EVIDENCE: Three resident files were sampled and both included booklets entitled ‘Assessments for good care planning.’ These included a lot of information about the individual including, a personal profile, assessments for physical and mental health, falls, pressure care, manual handling and personal risks as well as personal preferences and social needs. There was also a section that detailed the needs and preferences of the residents that included identified any needs in relation to such things as physical and mental abilities, health and hygiene and religious and cultural needs. From the details in the booklets a ‘day in the life’ was drawn up which detailed each individual’s daily routine and Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 11 these included their preferences, likes and dislikes and where staff were to offer assistance. These included some very detailed information about the needs of the residents, for example, has night light left on, can wash the top half but will need help with the bottom half, important to have an electric shave and preferred rising and retiring times. Care plans were being reviewed on a monthly basis. The daily recordings for the residents were very brief and did not give an overview of the care being offered to the residents or their general well being. Also on some days recordings had been missed. The importance of evidencing the care and assistance being offered to the residents was discussed with the acting manager and the proprietor and this was to be addressed. All the files sampled had the required risk assessments in place and included separate manual handling risk assessments that detailed the equipment to be used if the resident should fall. Two of the three included the sling size if the hoist was to be used. The acting manager was reminded that all risk assessments must include the sling size. One of the residents had some mobility difficulties and although this was detailed the type of assistance he required was not clearly detailed. The assessment stated ‘mobility with 2 helpers’ the type of assistance required needed to be detailed on the manual handling assessment. The daily records evidenced that any health care needs were identified by staff, followed up and monitored. Doctors’ visits were being recorded separately from the daily records which made them easy to track. Since the last inspection they were also mentioned on the daily records so that staff were aware a visit had taken place. There was evidence that where necessary residents saw the district nurses, one visited the home on the day of the inspection. The weights of the residents were being monitored and tissue viability and nutritional screenings had been undertaken. The home had recently changed the pharmacist they used to supply the residents’ medication, as they were unhappy with the service. The medication continued to be administered via a monitored dosage system but it was in weekly Nomad packs rather than 28 day blister packs. The system was well managed and only one very minor discrepancy was found in the amount of one of the resident’s paracetamol. All other medication audited was correct. Only staff who had received appropriate training administered medication. No residents were self administering their medication and no controlled drugs were being administered at the time of the inspection. The privacy of the residents was generally well maintained and respected. Residents could lock their bedroom doors if they wished, a lockable facility was available if required, there was portable screening for use in the double bedrooms and medical consultations took place in the privacy of the Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 12 individual’s bedroom. Staff were seen to knock on doors and wait for a response before entering. Stennards (Kn) DS0000016786.V328236.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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are no rigid rules or routines in the home and residents are encouraged to exercise choice and control over their lives. There are activities on offer that appear to meet with the needs of the residents but records of these were not being kept. The meals in the home are good with choices available. EVIDENCE: On the day of the inspection the atmosphere in the home was very relaxed and there were very good interactions between staff and residents. It was evident throughout the course of the inspection that the residents were content and that routines in the home were kept to a minimum. Residents were seen to spend time quietly in their rooms, wander around the home, watch television, listen to music, have one to one chats with staff, read and take part in an organised activity. The inspector was informed that a variety of activities were available for the residents to take part in if they wished. These were facilitated by staff as well as visitors to the home. The only activities staff were recording were visitors to see the residents and if residents went out. The importance of recording the social activities that the residents take part in or refuse as Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 14 evidence that their needs were being met was discussed with the acting manager and the proprietor and a system was to be put in place to ensure this was done. One of the residents attended a day centre four days a week. Others had the opportunity to attend a day centre at a Baptist church, which was a weekly event, and where they had the opportunity to meet with other residents from the other care homes also owned by the proprietors. All residents were registered with ring and ride to enable them to out. There were no restrictions on visitors to the home within reasonable hours. The inspector spoke with one visitor who described the home as ‘very nice, very homely’ and stated he was always made welcome when he visited. He also said he ‘felt as if he had known the proprietors for years’. Residents appeared very satisfied with the catering arrangements at the home and were seen having lunch and tea which they were clearly enjoying. Of particular note was the variety that the residents were eating at teatime which included, beans, tomatoes or spaghetti on toast, others had boiled eggs and others sandwiches. Meal times were quite flexible if that was what residents wanted. One resident got up quite a bit later than all the other residents and was given her breakfast straight away. The visitor spoken with stated that his relative had quite a small appetite and staff were aware of this and that when he had visited at meal times the food always looked very good. The menus were varied and nutritious and offered choices at all meals. Stennards (Kn) DS0000016786.V328236.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure at the home that is issued to all residents. The policies and procedures on site and the training staff received ensures staff are aware of the importance of protecting residents from abuse. EVIDENCE: There was an appropriate complaints procedure on display in the home and a copy of this was issued to all the residents in the welcome pack. No complaints had been lodged with the home and none had been received by the CSCI. The residents at the home were very comfortable in the presence of the manager, staff and the proprietors and very good relationships were evident. This gave residents confidence to raise any issues they had. The proprietor stated that if any issues did arise with residents or their relatives they would address them very quickly to ensure they did not get out of hand. The visitor spoken with confirmed this who said that any minor issues he had raised, for example, missing clothing were quickly addressed. Staff had received training in the protection of vulnerable adults and this was regularly updated. The policies and procedures in relation to adult protection, whistle blowing managing aggression and physical intervention were not viewed at this inspection. They had been seen previously and the inspector was informed no changes had been made. Stennards (Kn) DS0000016786.V328236.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, 20, 21, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers residents a safe, well maintained, comfortable and homely place to live. EVIDENCE: There had been no changes to the layout of the home since the last inspection. The home was well maintained, safe and comfortable. The pre inspection questionnaire detailed several improvements to the home since the last inspection. The majority of these were seen at the time of the visit and included: the kitchen had been totally refurbished and had new appliances, some bedrooms had been recarpeted and several areas had been redecorated. This is a large home and decoration and replacing of carpets and furniture is an ongoing issue for the proprietors. Some of the carpets in the upstairs corridors were showing signs of wear and tear however when mentioned to the Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 17 proprietors they were well aware of this and planning to replace it. The proprietors were very quick to act if any issues are raised about the environment. The fire officer last visited the home in November 2006 and no requirements were made. The environmental officer visited in February 2007 and made some minor requirements these had been addressed. As at previous inspections there was ample communal space at the home which comprised of two interconnecting lounges, a dining room and conservatory. The lounges were equipped with televisions, DVD players and there were music systems also available. The conservatory was used as a quiet area where residents could take their visitors if they wished. There was a large well maintained garden that was accessible to the residents. All the communal areas were well furnished and decorated. There were adequate numbers of toilets, bathrooms and showers in the home. Some of the facilities allowed for full staff assistance, for example, a floor level shower. Some of the bedrooms also had en-suite facilities. The aids and adaptations at the home appeared to meet the needs of the residents and included, assisted bathing facilities, hand and grab rails, ramped entrance, stair and shaft lift and emergency call system. The home also had a mobile hoist if needed. Some bedrooms were seen and they varied in size, were comfortable and adequately furnished and decorated. All were appropriately personalised to the occupants choosing. Residents could have keys to their rooms if they wished and lockable facilities were available. The premises was clean, hygienic and generally odour free. Two rooms did have an odour control issue however the home were doing all they could to address this issue. The laundry was appropriately located and there was a separate sluice facility. As at the last inspection it was recommended that when the washing was replaced one with a sluice cycle was purchased. As stated the kitchen had been refurbished and all the appropriate checks were in place for good food hygiene practice. Stennards (Kn) DS0000016786.V328236.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good staffing levels were being maintained by a well trained, long standing staff team who were able to meet the needs of the residents. Recruitment procedures were robust but needed to be applied consistently to ensure the safety of the residents. EVIDENCE: Staff turnover at this home is very low only two care assistants had left over the last year. The stable staff team provided residents with good continuity of care. Several of the staff had worked at the home for a considerable amount of time and their relationships with the residents were very good. The home also employed domestic and catering staff. Rotas showed that there were three care staff plus a senior on duty throughout the waking day as a minimum and two waking night staff. Residents were seen to be very comfortable in the presence of all the staff and the proprietors. The visitor spoken with was very positive in his comments about the staff team and the proprietors. The files for the two staff that had been appointed since the last inspection were sampled. All the required recruitment documentation was available and all the required checks had been undertaken. It was noted that both staff had Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 19 started their employment a few days prior to their POVA first checks being received by the home. This was discussed with the proprietor and she stated one employee was known to her personally and she knew the other had come from a home that was closing and had not been unemployed at all. She was reminded that in future this check must be obtained prior to staff commencing their employment. New staff were receiving induction training but this was done over two or three days and could not have covered all the areas required by the Skills for Care induction standards. There was a yearly training programme in place for all staff and all mandatory training was updated. Topics included adult protection, first aid, food hygiene, manual handling, infection control and fire procedures. Staff also received training in other topics such as, death, dying and bereavement and the role of the care worker. Over 50 of the staff employed at the home had NVQ level 2 and 5 also had NVQ level 3. Stennards (Kn) DS0000016786.V328236.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner with regular input from the proprietors. The health and safety of the residents and staff was well managed. EVIDENCE: At the time of the inspection the registered manager was on maternity leave. An acting manager was in post. She had worked for the proprietors for a considerable amount of time both at this home and another of their homes. She had gained a good knowledge of the residents in her care and was very receptive to all the comments during the inspection. The proprietors were very Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 21 regular visitors to the home and ensured the acting manager received any support she needed. The registered manager had her registered Manager’s Award but was having difficulty securing funding to complete the required modules of training for the NVQ level 4 in care. She was still pursuing this. The home had a quality assurance system in place that had been purchased from an outside agency that they were working their way through. The system involved seeking the views of the residents and any other stakeholders in the home including questionnaires, resident and staff meetings. The relatives of some of the residents and the residents themselves had just completed questionnaires. These were sampled and included the following comments: ‘ The quality of care my mother has received whilst at Stennards is excellent.’ ‘I cannot fault the quality of the service at all.’ ‘Very pleasant staff, good food, overall very pleased.’ ‘Attentive and kindly.’ ‘Very kind to me and friendly. I feel safe and like the company.’ ‘Good care, friendly atmosphere.’ A development plan for the service for 2007 had been drawn up by the proprietor and included a lot of detail of proposed activities for the residents as well as developments for the premises. The acting manager stated she did not manage any money for the residents. If residents required anything and they did not hold their own money it was purchased from petty cash and then relatives reimbursed the home. She was satisfied that all residents had access to money if they needed it. The health and safety of the residents and staff were well managed and staff received ongoing training in safe working practices. There was evidence on site that all the necessary equipment was regularly serviced. All the in house checks on the fire system were up to date and regular fire drills were undertaken. Accident and incident recording and reporting were appropriate. Stennards (Kn) DS0000016786.V328236.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 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Stennards (Kn) DS0000016786.V328236.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 OP7 Regulation 12(1)(a) Requirement The daily recordings for the residents must include evidence of their general well-being and the care being offered/given. Manual handling risk assessments must detail: The size of the sling to be used with the hoist. Any handling methods to be used by staff. 3. OP12 12(1)(a) Daily records must include details of how residents are spending their time to show their social needs are being met. There must be evidence on site that POVA first checks have been undertaken on staff prior to them commencing their employment. New staff must undertake induction training in line with the specifications laid down by Skills for Care and within the given time scales. The registered manager must be qualified to NVQ level 4 in care DS0000016786.V328236.R01.S.doc Timescale for action 14/04/07 2. OP7 13(5) 01/05/07 01/05/07 4. OP29 19 14/04/07 5. OP30 18(1)(a) 01/05/07 6. OP31 9(1)(a) 31/07/07 Stennards (Kn) Version 5.2 Page 24 and management or the equivalent. (Previous time scales of 31/12/05 and 30/06/06 not met.) 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 Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Stennards (Kn) DS0000016786.V328236.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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