Inspection on 26/01/07 for Stocks Hall

This inspection was carried out on 26th 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

Stocks Hall 11/12/07

Stocks Hall 24/03/06

Stocks Hall 19/10/05

Stocks Hall 24/02/05

Stocks Hall 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Stocks Hall 76a Nursery Avenue Nursery Lane Ormskirk Lancashire L39 2DZ Lead Inspector Val Turley Unannounced Inspection 26th January 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 Stocks Hall DS0000005909.V322149.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. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stocks Hall Address 76a Nursery Avenue Nursery Lane Ormskirk Lancashire L39 2DZ 01695 579842 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) Stocks Hall Care Homes Limited Mrs Ann Elizabeth Williams Care Home 45 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (18) of places Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 45 service users to include: Up to 18 service users in the category OP - (Old age, not falling within any other category) needing personal care only. Up to 27 service users in the category DE (E) Dementia (service users who are over 65 years of age) needing personal care only. The registered person must at all times, employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the National Care Standards Commission regarding staffing levels in care homes. 24th March 2006 2. 3. Date of last inspection Brief Description of the Service: Stocks Hall care home provides 24-hour personal care and accommodation for the elderly and people who have care needs associated with dementia. Stocks Hall is owned by Stocks Hall Care Homes Limited and is one of four homes managed by the company. The home is situated in a quiet area of Ormskirk, close to the town centre, near to shops, pubs and post office. Ample car parking is available at the front entrance with garden areas and a larger garden at the rear of the home. The premises are a two storey purpose-built property. Bedroom accommodation is on both floors. All bedrooms are single and several of these rooms have an en-suite facility. Lounge and dining rooms are also located on both floors. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedroom and living rooms. Charges at the home range from £320 - £435 per week. There are additional charges for chiropody, optical care, dental care, outings and hairdressing, toiletries, papers and magazines, transport and private telephones. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection that took place over a period of eleven months and culminated with an unannounced site visit over one day in January 2007 by one regulatory inspector. The inspection involved discussion with service users living at the home, visiting relatives and staff working there, observation of staff supporting service users and an examination of records, policies and procedures. Information provided on a comment card which had been completed by a relative, was also included within the report. Information from a pre-inspection questionnaire completed by the manager of the home, was also in the report. As part of the inspection, the inspector used ‘case tracking’ as a means of assessing some of the National Minimum Standards. This process enabled the inspector to focus on three of the service users living at the home. Records relating to those individuals were inspected and discussion took place with the service users where this was possible. What the service does well: Stocks Hall provides a clean, comfortable, tidy, safe and homely environment for the service users who live there and the staff who support them. All of the service users and relatives consulted as part of the inspection process were very satisfied with the care and support provided by the home. Service users were involved in making decisions about the care that they received as far as they were able. The home had a good admissions procedure, with service users being thoroughly assessed before admission so that the home could make sure that they were able to meet the needs of each resident. Care plans were generally good and included most of the support needs of the service users. The care plans were reviewed on a monthly basis enabling the changing support needs of the service users to be recorded and any additional support to be provided. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 6 Medication within the home was generally well managed helping to ensure that the health needs of the service users were attended to. Additionally the home had good working relationships with a range of health and social care professionals who provided additional input and guidance in the home, helping to improve the quality of life for the service users. From discussion with service users, visitors and staff and from observation of the staff providing support to the service users, it was clear that the daily routines within the home were flexible and varied enabling the service users to make choices about their own routines. Service users were free to move about the home and were given choices by the staff as to what they wanted to do. Visitors were able to visit at any reasonable time. Bedrooms were personalised with service users being able to bring in their own possessions, furniture and pictures. The service users enjoyed the food provided at the home and the cook had a good knowledge of the individual dietary needs, likes and dislikes of the service users. The home benefited from a well-established group of staff that knew the service users well. Service users said ‘the staff are good, they will do anything they can to help’. The homes policies and procedures in relation to the protection and safeguarding of the service users were comprehensive and helped ensure that the service users were protected as far as possible. There had been one referral received in relation to the protection and safeguarding of vulnerable adults and the home had responded to this appropriately and had co-operated with those agencies involved. The staff felt well supported by the management team and had started to adopt new routines of working, which they felt improved the running of the home and improved the care provided for the service users. Some staff felt better motivated with the additional responsibilities they had been given. Over 60 of the staff team had achieved a nationally recognised qualification in care, providing them with a good range of skills and experience. The home had a number of quality assurance monitoring systems in place which all helped to make sure that the home was run safely and with the interests of the service users in mind. What has improved since the last inspection? Since the last inspection the home had reviewed and updated its policy that deals with the management of challenging behaviour, providing staff with up to date information and guidance. It had also reviewed its medication policy and procedure, improving its practice and improving the safety of service users. Staff had also been provided with information on the safe use of bedrails. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 7 A range of risk assessments had been undertaken for each of the service users and these had been reviewed monthly. A standard approach had been adopted for these assessments, which made it easier for staff to understand. What they could do better: There were a number of ways in which the care planning process could be improved. The care plans could be more detailed to give staff more information about the service users support needs including some areas of personal care and their hobbies and interests. The daily record of care provided could also be more detailed to give staff a clearer picture of the care the service users have received and need. The management of medication could also be improved to help protect service users. Photographs of service users should be included on the medication administration record (MAR sheets) to help staff identify service users correctly. Any handwritten entries on the MAR sheets should be checked and countersigned by a second member of staff to reduce the risk of errors being made. It was noted that the patio to the rear of the home gives access to the laundry and maintenance workshop. The area should be made secure to allow the service users to access and enjoy the patio safely. It was recommended that the staffing levels are reviewed regularly and adjusted taking the needs of the service users into account and the also the lay out of the building. The manager must also continue in her efforts to ensure that staff attend all mandatory training courses and refresher courses to keep their skills updated. The registered person must ensure that all necessary checks have been undertaken and the necessary documentation is in place for all persons before they start to work at the care home. This will help to protect the service users. Please contact the provider for advice of actions taken in response to this Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 8 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. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 9 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 Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 10 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 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the service users were assessed before admission to the home, enabling the home to decide if they could meet their needs safely. EVIDENCE: The files of three service users were examined. These showed that the home had received an assessment of their individual care needs or had undertaken an assessment of the service user themselves before they were admitted to the home. This enabled the home to make a decision as to whether they could provide the necessary support. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 11 The home had a small intermediate care unit with its own dedicated space enabling specialised care to be provided without intruding on the lives of the other service users in the home. There was evidence here that there was input from a range of health professionals. On the day of the visit to the home the acting manager stated that the home was reviewing the way in which referrals are made to the intermediate care unit. This was to ensure that those service users admitted could make best use of the support provided and also that the staffing levels and expertise of the staff matched the needs of the service users. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 12 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 care planning process was generally good and staff were provided with the information needed to meet the individual needs of the service users. EVIDENCE: All three of the service users files examined contained a care plan. The plans contained most of the information required to meet the support needs of the individual service users. Some improvements could have been made to the plans, giving staff more information about each of the service users and enabling them to provide more individual support. Examples of this were: - the plans did not always contain Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 13 the details of the service users interests and hobbies, although this information was available elsewhere in the service users file; if a service user wore glasses this was not always carried over to the care plan and there were no details as to when the service user needed to wear glasses. There was also no detail of any mouth care needs within the care plan although this information was available within the needs assessment undertaken by the home. There were some good examples of service users individual needs and preferences being recognised that were included in the plans e.g. one service user preferred to sleep at night with the curtains open. Another care plan included the service users wishes visit the hairdressers regularly. There was evidence of service users and relatives being involved in the development of the care plans and also evidence that the plans were reviewed on a monthly basis, enabling the changing needs of the service users to be recognised and met. There was evidence that the health needs of the service users were met. Records showed that a number of health and social care professionals were routinely involved in the home. These included GP’s, District Nurses, occupational therapists, a continence advisor, a seating specialist, practice nurses and an optician. A service user and a visiting relative confirmed that services had been provided by health professionals and that the home had supported the service user to attend hospital appointments. On the day of the visit staff were observed to arrange visits by GP’s and to liaise with district nurses and social workers. Equipment was provided through the District Nurses to help prevent the incidence of pressure sores. District Nurses also provided bed rails where necessary and the home provided guidance for staff to help keep service users safe when bed rails were being used. The home had a number of risk assessments in place, including nutritional assessments that were reviewed on a monthly basis. These also enabled staff to monitor the service users progress and provide additional support where necessary. The home had recognised that it needed to improve on its daily record keeping to ensure that the support and care received by service users could be monitored more accurately. Staff had already started to make more detailed records. Medication in the home was generally well managed. Some recommendations were made to build extra safeguards into the procedures and so protect the service users still further. Since the last key inspection the home had reviewed its medication policy and acted upon advice with regard to the secondary dispensing of drugs. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 14 Staff were observed to speak appropriately to the service users and treat them with respect. Service users said ‘the staff are good, they will do anything they can to help’. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 15 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. Service users were given opportunities to make choices and decisions about their daily life in the home. EVIDENCE: The atmosphere in the home was relaxed and the service users spoken to said that they were able to make choices about their daily lives. Visitors were able to visit the home at any reasonable time and could visit service users in the privacy of their own room. One visitor spoken to on the day of the visit to the home said he felt comfortable visiting the home and that staff were approachable. Service users were able to personalise their rooms with their own belongings helping them to feel comfortable and settled in the home. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 16 Ministers from the local churches visited the service users at the home on a regular arranged basis. Activities were arranged in the home by the activities organiser and additional activities were arranged by the staff throughout the home. Discussion with a member of staff within the intermediate care unit showed that she was sensitive to the needs of the individual service users and provided them with the support they needed to participate in activities when they wished to. Details of the service users interests and hobbies weren’t always included within the care plans. This information would enable staff to support service users to follow their own interests and hobbies on a 1-1 basis where staffing levels permitted this. The home arranged for entertainers to come into the home and organised different events throughout the year including day trips, quizzes and celebrations on birthdays. Mealtimes were observed over the three units within the home. Service users were able to choose from the different meals on offer and four of the service users spoken to said that they enjoyed their meals very much. Staff were observed supporting service users to eat their meals where this was needed and they did this sensitively and at the pace of the individual service users. The cook and the staff at the home were very aware of any dietary needs and preferences for each of the service users and meals were served according to their individual needs. The kitchen at the home had good stocks of fresh, chilled and dry foods. The home had links with two advocacy agencies that provided independent advice and guidance and service users and relatives were given details of how to contact these. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 17 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 homes policies and procedures in relation to the safeguarding of vulnerable adults helped to ensure that service users were protected as far as possible. EVIDENCE: The home had a comprehensive complaints policy in place, which included all of the required detail and outlined the steps that could be taken if service users were unhappy with the service provided. The policy was made available to service users and their relatives. The homes policies and procedures dealing with the protection of vulnerable adults and the management of challenging behaviour had been updated to reflect good practice and guidance for staff was made available within the home giving them information as to the action they should they become aware of any allegations that may be made. Since the last key inspection one referral in relation to the safeguarding of vulnerable adults had been received. At the time of the visit to the home the Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 18 investigation into this was ongoing. The home had acted responsibly in relation to this enquiry and was co-operating with the agencies concerned. Since the last inspection the home had circulated information to the staff about the safe use of bed rails and this was available in each of the offices throughout the home. As the District Nurses provided the bedrails there was an assumption that the nurse took responsibility for their safe use. This needs to be clarified to make sure that this is the case or if the home need to take further steps to ensure that service users are protected when bedrails are used. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 19 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 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 provided a clean and comfortable environment for both service users and staff. EVIDENCE: The laundry at the home was clean and well organised. Guidance was in place for staff regarding infection control and protective clothing was available for use by the staff. The home itself was clean, tidy and homely. There was a rolling programme underway to redecorate and re-carpet the corridors and those bedrooms where Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 20 it was needed. There were also plans to improve the lighting throughout the homes to provide a safer environment for the service users and staff. There was a patio area with benches to the rear of the home that service users could use in the warmer months. There were plans to upgrade this area and provide some raised beds for service users to enjoy. It was noted that there was direct access to the laundry and maintenance department from the patio. A gate must be installed to screen off this area and enable the service users to access the patio safely. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 21 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. The homes recruitment procedures and training programme did not ensure that the staff team were appropriately selected and had the skills to meet the needs of the service. EVIDENCE: The home benefited from having a well-established staff team who were familiar with the individual support needs of the service users. Over 60 of the staff team had achieved a nationally recognised qualification in care, providing them with a good range of skills and experience. The senior members of the staff team had recently been given more responsibility with regard to the day-to-day running of the home. One senior member of staff spoken to said that they were happy with the changes and that felt better motivated because of them. Those staff spoken to said that Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 22 they felt generally well supported by the homes management team although some had been unsettled by the recent changes. The home had recognised that its mandatory training record needed to be improved. Staff had not routinely taken up this training and any refresher training and a deadline had been introduced to ensure that staff did complete this training. This lack of training left the service users and staff in a possible position of risk as staff would not necessarily be aware of current good practice in a number of areas including moving and handling, protection of vulnerable adults and the management and administration of medication. The manager had recognised the need to review the staffing levels in the home and perhaps the need to have different numbers of staff on duty at different times of day. This had been discussed with the staff who also recognised the need for some re-organisation. It was recommended that staffing levels be reviewed on a regular basis based on the dependency needs of the service users and the lay out of the building. The files of three recently appointed members of staff were examined. From the documentation in place it was clear that the home was aware of the procedures to follow when appointing staff, however these had not always been followed. Criminal Record Bureau checks were in place for those staff whose records were examined and although references were always requested, the home had appointed staff even where these had not been returned. This approach left service users at risk. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 23 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 that the home was run in the best interests of the service users. EVIDENCE: The manager was experienced, competent and qualified to run the home and meet its stated aims and objectives. There were clear lines of accountability within the home and the staff felt well supported. Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 24 The home had a number of quality assurance monitoring systems in place that were designed to ensure that the service users received the support that they needed. The home had achieved the Investors in People Award which is a quality assurance award awarded by an outside body. It had also achieved the Work Life Balance Award. Monthly monitoring visits were made to the home and reports of these forwarded to the commission. An external auditor also undertook an annual audit of the home, providing additional opportunities for any shortfalls to be recognised and acted upon. Policies and procedures were reviewed and updated as necessary to ensure that staff were aware of their responsibilities. A service users survey had been undertaken in December 2006 and the views of health and social care professionals were also sought. Unfortunately the home had received a poor response to these surveys so no meaningful conclusions were made on the basis of the information returned. The home safeguarded the service users financial interests as far as it was able. Small amount of money were held for the service users. These were maintained individually and receipts were kept for any purchases made. The home also maintained an inventory of service users possessions and gave receipts for any valuables held on behalf of service users. The homes equipment and systems were serviced and maintained appropriately to help ensure the safety of both service users and the staff working at the home. Accidents were recorded appropriately and reported to the appropriate agencies when necessary. Training was made available for staff in safe working practices although this had not always been taken advantage of. This was a concern that the manager had addressed and the staff spoken to were fully aware of their responsibilities to attend these training courses within the timescale specified (See Standard 30). Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 25 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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 X X X X X 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 3 X 3 X 3 X X 2 Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 13(4)(c) Requirement The registered person must clarify who has ongoing responsibility for the safe use of bed rails. The patio must be made safe for service users to access. The registered person must ensure that all necessary checks have been undertaken and the necessary documentation is in place for all persons before they start to work at the care home. (Previous timescale of 30/04/06 not met) The registered person must ensure that staff attend all mandatory training courses Timescale for action 31/03/07 2. 3. OP19 OP29 23(2)(o) 19(5) 30/04/07 31/03/07 4. OP30 13(5) 30/06/07 Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 27 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 3 4. Refer to Standard OP7 OP7 OP9 OP9 Good Practice Recommendations Care plans should be more detailed to give more information about the service users support needs. The daily record of care provided to service user on a daily basis should be more detailed. Medication administration records should include a photograph of the service users Any handwritten entries on the medication administration records should be checked and countersigned by a second member of staff. Details of the service users interests and hobbies should be included in the care plans. Staffing ratios should be reviewed regularly and adjusted as necessary to reflect the needs of the service users and the take into account the layout of the building. 5. 6. OP12 OP27 Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Stocks Hall DS0000005909.V322149.R01.S.doc Version 5.2 Page 29 - 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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