Inspection on 04/01/07 for Stennards (Mos)

This inspection was carried out on 4th January 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 (Mos) 24/11/08

Stennards (Mos) 08/12/05

Stennards (Mos) 09/06/05

Stennards (Mos) 25/01/05

Stennards (Mos) 24/08/04

Stennards (Mos) 05/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

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 (Mos) 133 Anderton Park Road Moseley Birmingham West Midlands B13 9DQ Lead Inspector Brenda O’Neill Key Unannounced Inspection 09:30 4th January 2007 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 (Mos) DS0000016787.V313295.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 (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stennards (Mos) Address 133 Anderton Park Road Moseley Birmingham West Midlands B13 9DQ 0121 449 4544 F/P 0121 449 4544 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) Mr Peter David Lee-Harris Mrs Dawn Lee-Harris Ms Catherine Coughlan Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Stennards Leisure Moseley is a large detached building situated in a residential area of Moseley. It is close to the centre of Moseley with easy access to public transport. The home currently offers residential care to 16 older adults and day care to one older adult. The home aims to provide residents with the opportunity to participate in communal activities such as music, progressive mobility and bingo in the home or to go out for daytime activities at a church centre once a week with transport being provided by Ring and Ride. The accommodation comprises of ten single and three double bedrooms, eight of which have en-suite facilities. The remaining rooms have a wash hand basin. In addition the home has three bathrooms and one shower facility. There are toilets located near to the communal areas. There is also a lounge, dining room and a conservatory which are comfortably furnished and nicely decorated. The kitchen is located off the dining room and has a small room attached for washing up and food preparation. The laundry, sluice and some storage areas are located off this room. There is a well maintained, secluded garden to the rear of the home that is accessible from the conservatory. Off road parking is available at the front of the home. Fees at the home range from £331.00 to £345.99 plus £15.00 per week top up. Stennards (Mos) DS0000016787.V313295.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 unannounced inspection over one day in January 2007. During the course of the inspection a tour of the premises was undertaken, three resident and four staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, three staff members and three of the fourteen residents. Prior to the inspection the manager had returned a completed pre inspection questionnaire to the CSCI which gave additional information about the home. The inspector also received eight completed comment cards from relatives and professionals who visit the home and five from residents. All the comments received about the service offered at the home were very positive. The home had not received any complaints since the last inspection and none had been lodged with the CSCI. What the service does well: This home consistently offers a good service to the residents living there. This was reflected in the comments received from visitors to the home most of whom were relatives of the residents. Comments included: ‘I am very satisfied with the care at this home.’ ‘Good environment and happy atmosphere for patients.’ ‘My relative is cared for extremely well and is very happy here. The staff are all very friendly and can be approached with any problem you have. We are happy to know she is safe.’ ‘Even though I live some distance from Birmingham I feel really confident to leave my relative in the very good care of Stennards.’ ‘When arriving here it’s like going into a family home, patients always happy and content, and there is no unpleasant smell at all.’ ‘My relative has thrived since her arrival here. It is as near to her own home as is possible.’ The home had very low staff turnover and several of the staff had worked there for a number of years which was very good for the continuity of care of the residents. Staff training was very high on the agenda at the home and the proprietor was very involved in ensuring staff were adequately trained to fulfil their roles. There was good evidence that showed the residents health care needs were being met and that they saw the appropriate health care professionals as necessary. The medication administration system was well managed and safe. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 6 There were no rigid rules or routines in the home and there were a variety of activities on offer for those residents who wished to take part. The meals at the home were varied and nutritious and residents were offered choices at all meals. Snacks were available for residents at all times. The home offers residents a safe, well maintained, comfortable and homely place to live. The manager had worked at the home for a number of years and demonstrated a very good knowledge of the needs of the residents in her care and the running of a residential home. She was very receptive throughout the inspection to any suggested changes. It is known by the inspector that both the manager and the proprietors of the home are quick to respond to any requirements made during inspections. What has improved since the last inspection? What they could do better: Residents who are privately funded must have a comprehensive assessment undertaken that identifies their needs to ensure the home can make an informed decision as to whether they can meet their needs. All placements at the home need to be reviewed after the four week trail period to ensure the residents are happy with the service being offered and that the home can continue to meet their needs. Care plans needed to reflect all the current needs of the residents and detail of how staff were to help the residents meet these needs. Where any risks are identified for residents there must be a management plan in place detailing how the risk is to be minimised. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 7 Daily records needed to be further developed to ensure they gave an overview of the residents’ health and welfare on an ongoing basis. This will enable any progress or deterioration to monitored more closely. To further enhance the infection control procedures in the home all hard soap needed to be removed from communal bathrooms and toilets. To ensure the protection of the residents the manager needed to ensure that all the appropriate checks were undertaken for new staff prior to their commencing their employment. 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 (Mos) DS0000016787.V313295.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 (Mos) DS0000016787.V313295.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 adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents had the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the home. The assessment procedures for self funding residents needed to be further developed to ensure the needs of the residents were known and could be met by staff. EVIDENCE: The files for the two residents admitted to the home since the last inspection were sampled. One of the files included a copy of the pre admission assessment undertaken by the social worker involved in the admission and an assessment undertaken by staff on the pre admission visit to the home. The other file was for a privately funded resident. This included an assessment undertaken by the staff at the home on the pre admission visit. This covered all the required areas but the format used was a tick box for each area and a small area for additional comments and this did not identify the reason for Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 10 admission or any of the specific needs of the individual. This issue was discussed with the manager at the time of the inspection and it was suggested that all information gained about prospective residents was documented. It was also noted that for residents who were self funding the placement was not being reviewed after the four week trial period. This needed to be carried out and documented to ensure the placement was suitable for both the individual and the home. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Care plans and risk assessments did not always reflect the current needs of the residents. Health care needs were being met and the systems for administration of medication were good ensuring resident’s medication needs were met. EVIDENCE: Three resident files were sampled. They included booklets entitled ‘Assessment for good care planning’. These included information about the individual and assessments for mental and physical health, falls, pressure care, manual handling and personal risks, personal preferences and needs, which included health and hygiene, and social and cultural needs. Also included were lifting assessments which detailed what staff were to do if the individuals fell and were uninjured. The manager needed to further develop these because where the use of a hoist was detailed the sling size had not been included. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 12 Daily profiles had been drawn up for each resident which detailed the individuals’ daily routine and how and when staff were to offer assistance. One of those seen had been drawn up the day after admission and had not been updated since. It was evident when speaking to the manager that some of the profile was no longer applicable and some needs were not detailed, for example, it stated wears a hearing aid when the person would not actually wear this and the mental health assessment stated short term memory loss but there was no mention of how this reflected in the daily care of the individual. For another resident there was evidence on the pre admission visit record they had a catheter fitted but this was not mentioned on the daily profile as to whether staff had to attend to this or the individual was able to do this for themselves. Other issues that were not addressed in the profiles were how any challenging behaviours were to be managed by staff. One resident could be a little verbal at times and this was not reflected in their risk assessments and there were no management plans in place for this. These issues were discussed with the manager and the need to have management plans in place for any needs the residents may have in relation to behaviours or health care. Despite the above issues not being documented it was evident that staff were aware of them and the needs of the residents were being met. Daily profiles did detail the preferences of the residents in relation to times for getting up and going to bed, baths or shower, their needs at night, for example, has bedside light left on. Also detailed in the majority of cases were the residents’ abilities to self care, for example, can choose there own clothes, will brush their own teeth. There was evidence that when any health care needs of the residents were identified they were followed up. Health care visit records detailed regular reviews by the G.P., visits from the chiropodist, dentist and district nurse as necessary. There were also details of attendance at hospital appointments when necessary. Tissue viability and nutritional screenings had been undertaken. Not all the residents were being weighed on a regular basis. This was discussed with the manager and she could not identify why some residents were not being weighed. The daily records being kept for the residents were very repetitive and did not give an accurate overview of the health and welfare of the residents. The format being used for the daily recordings was very restrictive and did not allow for staff to comment on all aspects of the residents’ lives. For example, one resident had a small wound on her arm with a dressing on it but there was no mention of this on her daily records. There was no space for such things as night staff to record if anyone had had a disturbed night and what they had done about this, if anyone had a fall or for the presenting symptoms to be included if anyone was feeling unwell. This was discussed with the manager and she was to address this. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 13 The majority of the medication was administered via a 28 day monitored dosage system which was well managed. All medication was being acknowledged when received into the home and copies of prescriptions were being kept. Medication that was being administered from boxes was audited and all the balances held in the home corresponded with what had been received and what had been administered. No homely remedies or controlled drugs were being held in the home at the time of the inspection. All staff that administered medication had received the appropriate training. There were no issues raised during the course of the inspection in relation to the privacy and dignity of the residents. Residents could lock their bedroom doors and there were lockable facilities available if they wanted them and double rooms had appropriate screening. Staff used appropriate terms of address when speaking to the residents. Residents were able to spend time in their bedrooms if they wished and medical consultations took place in the privacy of their bedrooms. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and residents were encouraged to exercise choice and control over their lives. There were a variety of activities on offer to try and ensure the residents social and religious needs were met. The meals in the home were good with choices available at all meals times. EVIDENCE: There were no rigid rules or routines in the home and there was a very relaxed atmosphere. Residents were seen to wander freely around the home, spend time chatting together, spend time in their room and take part in an activity during the afternoon. Documented activities that were facilitated by staff included board games, bingo, quizzes, cards and films. Outside entertainers regularly visited the home including progressive mobility for exercise to music and a musician. The home also had a selection of large print books delivered monthly from the local library and fashion shows every 4 months. Church of England services were held on a monthly basis and communion every week. Several of the service users attended a day centre once a week at a Baptist Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 15 church. Transport for this was provided by ring and ride and all residents were registered with this service. During the summer months residents often visited Kings Heath Park for a meal in the tearooms. There were no restrictions on visitors to the home. There was documented evidence of relatives of the residents visiting at various times throughout the day and on occasions joining residents for a meal. Some of the residents who had spouses had spent a lot of time with them in the home over the Christmas period. Several completed comment cards were received from visitors to the home and these were all very complimentary about the service offered at the home comments included: ‘When arriving here it is like going into a family home.’ ‘It is as near to her own home as is possible to be.’ ‘The staff are all very friendly and can be approached with any problem.’ ‘I am very satisfied with the care at this home.’ Residents were able to exercise choice and control over their lives. They chose when to get up and when they wanted to go to bed. There were details on the profiles of residents being able to choose their own clothes and meals. Residents were able to choose whether they took part in the activities provided by the home. During the course of the inspection one resident chose not to have their lunch at the same time as the other residents and was seen eating it later, another chose not to have lunch but requested a sandwich mid afternoon which was given by staff. All the bedrooms seen were personalised to the occupants choosing and residents could spend time in their rooms of they chose to do so without being disturbed by staff. The menus seen offered a good variety of meals with choices available at all meals times. For breakfast residents could choose from a variety of cereals, toast, boiled eggs, bacon sandwiches or cooked breakfast. Fresh fruit and snacks were available at all times for residents. As mentioned previously residents were able to choose not to have their main meal at the same time as other residents. They did not have to eat in the dining room if they did not want to. Records of food were being kept. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. The training staff received along with the policies and procedures on site ensured the residents were protected from harm. EVIDENCE: The home had not received any complaints and none had been lodged with the CSCI. The complaints procedure was not inspected but it met the required standard at the previous inspections. Relationships between the staff residents and their relatives were very good which gave them confidence to raise any issues that may arise. Relatives commented: ‘I feel very confident to leave my mother in the very good care of Stennards.’ ‘ We are happy to know she is safe.’ Policies and procedures were held on site for adult protection. These were not viewed at this inspection but met the required standard at previous inspections. All staff had received training in adult protection issues and this was regularly updated. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. 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. Some issues had been raised by the fire officer on his most recent visit to the home about the locks on the front door but these had been addressed very quickly by the proprietors. Communal space at the home includes a lounge, dining room and conservatory. All the communal areas had a variety of furnishings which helped give them a more homely feel. The space in the dining room was quite Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 18 limited but there was also a dining table available in the conservatory if needed. There were adequate toilets and bathrooms throughout the home. Several of the bedrooms had en-suite facilities of wash hand basin and toilet. There were three bathrooms throughout the home one of which had had a new bath hoist seat installed for those residents that needed assistance. There was also a shower room that had floor level access and allowed for full assistance from staff. There were some aids and adaptations throughout the home including, grab and hand rails, emergency call system and stair lift which appeared to meet the needs of the present resident group. Since the last inspection the emergency call system had been upgraded so that calls could only be cancelled from where they were made. This ensured staff had to answer the call and could not turn off the call and forget about it. It was pleasing to note that assessments had been undertaken for those residents who used wheelchairs in relation to footrests being used. Where footrests were not being used this was documented on the appropriate care file with the reason why. Bedrooms were redecorated on an ongoing basis and generally when they were unoccupied they had new flooring fitted. Bedrooms varied in size were bright, airy and comfortable. All bedrooms were personalised to the occupants choosing. The home was clean and hygienic. Two issues were raised with the manager to further enhance the infection control procedures in the home. There were personal toiletries in some of the bathrooms which needed to be returned to the residents’ rooms after use. There were several communal toilets and bathrooms where there were tablets of soap although there was also liquid soap. All hard soap needed to be removed from communal areas. The kitchen was clean and tidy. The manager commented that the kitchen was to be refitted and retiled at the end of January. The laundry, sluice and some storage areas were located off the kitchen area but it was not necessary for laundry to be taken through the kitchen, as there was an alternative route. It was strongly recommended that when the washing machine is replaced one with a sluice cycle is purchased. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Appropriate staffing levels were being maintained by a long standing, well trained staff team that was very good for the continuity of care of the residents. To ensure the safety of the residents the manager needed to undertake all the appropriate checks on staff members prior to their commencing their employment. EVIDENCE: Staff turnover at the home is very low and many of the staff have worked there for a number of years which was very good for the continuity of care of the residents. Staffing levels were appropriate for the needs of the residents and the manager’s hours were generally supernummery. Relationships between the staff team and the residents were very good. It was noted on the pre inspection questionnaire that three staff were working 50 hours a week on an ongoing basis, one of these being the manager. This was discussed with the manager and it was recommended that this is monitored and reviewed on an ongoing to ensure that it is not to the detriment of the individuals’ health. One new care assistant had been appointed since the last inspection. The recruitment records for this individual were checked, there were no references on file but the manager stated they were possible at one of the proprietors Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 20 other homes as this is where the interview took place. Copies of these were sent to the inspector after the inspection. The manager was reminded that these need to be kept on site where the person worked. It was also noted that the POVA first check had not been obtained until after the person had commenced work at the home. The manager stated that the person was well known to her and had worked for them previously. The previous employment was several years ago and the person had been employed at other care homes since therefore it was essential that a POVA first check was obtained prior to them commencing their employment. This issue had been raised with the manager at the previous inspection. All but one member of staff employed at the home had achieved NVQ levels 2, 3 or 4 which was commended. All staff undertook training on a yearly basis in a variety of topics including manual handling, fire procedures, food hygiene, adult protection and first aid. Other training topics covered by staff included death and dying, medication training, principles of care and one member of staff had just completed the intermediate food hygiene course. Other training planned was pressure relief to be facilitated by the district nurses and dementia care that was being explored with one of the colleges. New staff undertook induction training. Training was very high on the agenda at the home and the proprietor was very involved in ensuring staff were adequately trained to fulfil their roles. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The health and safety of the residents and staff were well managed. EVIDENCE: The manager had worked at the home for a number of years and demonstrated a very good knowledge of the needs of the residents in her care and the running of a residential home. She was very receptive throughout the inspection to any suggested changes. It is known by the inspector that both the manager and the proprietors of the home are quick to respond to any requirements made during inspections. The manager received regular support from the proprietors who visited the home virtually every day. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 22 Relationships between the manager, staff and residents were very good and residents were very comfortable in her presence. The proprietors are in the process of implementing a quality assurance system in all of their homes. The system calls for the homes to be audited against a set of standards which will highlight any areas for further development. The manager was advised that once the audits have been completed a yearly development plan for the home should be produced detailing how the service will be further improved. Resident and staff meetings were being held on a regular basis at the home where a variety of topics were discussed. There were also occasional questionnaires about the service that were completed by residents and or their relatives/representatives. The manager did not handle any finances on behalf of the residents. Some residents held small amounts of money of their own others had their money managed by their relatives. If a resident required anything purchased this was done by the home and then the appropriate relative reimbursed the home. The manager was satisfied that all the residents had access to money as needed. The health and safety of the residents and staff were well managed at the home. Staff received all the appropriate training in safe working practices. There was a maintenance book that was completed by staff as issues became apparent. Day to day maintenance was then undertaken either by the maintenance operative or one of the proprietors. This was always done promptly. There was evidence on site of the regular servicing of all equipment. The in house checks on the fire system were up to date and fire drills were being carried out regularly. The fire risk assessment was reviewed regularly and had been seen by the fire officer at the most recent visit and was appropriate. The reporting of accidents and incidents to the CSCI was being carried out appropriately. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 14(1)(2) Requirement Residents who are privately funded must have a comprehensive pre admission assessment undertaken that identifies their needs and reason for admission. Timescale for action 14/02/07 2. OP7 15(1) Placements at the home must be reviewed after the four week trail period to ensure it is suitable for all parties concerned. All residents must have care 14/02/07 plans in place that detail how all their current needs in relation to health and welfare are to be met by staff. Where lifting assessments detail the use of a hoist the size of the sling to be used must be detailed. Risk assessments must be updated as the needs of the residents change. Where any risks are identified there must be a management plan in place detailing how the 01/02/07 3. OP7 13(5) 4. OP7 13(4)(c) 14/02/07 Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 25 5. OP8 12(1)(a) 6. 7. OP8 OP26 12(1)(a) 13(3) risk is to be minimised. Daily records must be further 14/02/07 developed to ensure they give an overview of the health and welfare of the residents on an ongoing basis. Residents’ weights must be 01/02/07 monitored on an ongoing basis. All personal toiletries must be 01/02/07 returned to residents’ bedrooms after use. All hard soap must be removed from communal bathrooms and toilets. All staff must have a minimum of 01/02/07 a POVA first check before they commence their employment unless they are fully supervised at all times. (Previous time scale of 01/01/06 not met.) 8. OP29 19 Sch 2 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP26 OP27 Good Practice Recommendations It is strongly recommended that when the washing machine is replaced one with a sluice cycle is purchased. It is strongly recommended that where staff are working 50 hours per week this is monitored and reviewed on an ongoing basis. Stennards (Mos) DS0000016787.V313295.R01.S.doc Version 5.2 Page 26 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. 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