Inspection on 06/06/05 for Stokefield Care Home

This inspection was carried out on 6th June 2005.

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

Stokefield Care Home 19/06/07

Stokefield Care Home 22/09/05

Stokefield Care Home 09/11/04

Stokefield Care Home 14/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Stokefield Care Home St Johns Hill Road Woking Surrey GU21 1RG Lead Inspector Mrs Sue McBriarty Unannounced 6th June 2005 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 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. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stokefield Address St Johns Hill Road Woking Surrey GU21 1RG 01483 761779 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hanover Friends Elizabeth Ann Duddridge Care Home 16 Category(ies) of OP - Old Age (16) registration, with number of places Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Older age not falling within any other category (16). Date of last inspection 9th May 2004 Brief Description of the Service: Stokefield care home is owned and managed by Hanover Friends. The homes communal facilities are two (2) day rooms and a dining room, the bedrooms are all single rooms. The bedrooms include compact sitting and kitchen facilities. The home has specialist bathing facilities and equipment. The care home is situated in close proximity to Woking town centre and local amenities can be accessed through the homes own transport or community transport. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first for 2005 – 2006. This inspection focussed on the changes taking place within the care home with regard to the current building work and documentation completed in respect of residents and staff. A short tour of the building took place including the grounds and part of the refurbishment programme was seen. Documents sampled by the inspector included the Statement of Purpose, Service User Guide, staff personnel files and resident’s files. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5, Prospective residents and their families have the information they need to make a decision before moving into the home. The home provides residents with written contracts. A minor adjustment was required to complete the service user’s guide. Standard six (6) is not applicable. EVIDENCE: The home has a statement of purpose that is adequate to the needs of the home. One minor amendment was still required. The service user guide details the home’s complaints procedure, however it does not note the timescale for a response to a complaint. A previous requirement had been made to complete the update of the Service Users Guide by 30th June 2005. This date will remain as this inspection was completed on the 6th May 2005. The resident files sampled showed that they had been assessed prior to moving into the home. The statement of purpose stated that people were welcome to visit the home before making a decision as to whether to move in. Each of the files sampled had a signed and dated contract stating what the terms and conditions were of the residents stay in the home. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, The home provides care plans and risk assessments that adequately state the needs of the residents. EVIDENCE: The files sampled during this inspection evidenced details of the resident’s needs and how they would be met. The care plans had been reviewed and signed by the resident and or their representative. Details of the residents health needs were also clear and related risk assessments had been provided. The medication administration records were seen. Staff had just started the records at the time and therefore evidence over a period of time was not seen in the current records. However previous records were held on a separate file and a number were seen and noted by the inspector. At the front of the medication administration file evidence was seen that a senior member of staff checks and signs each day that the record is correct and complete. Those resident’s who self-administer medication had signed and dated a risk assessment to acknowledge their responsibility for their own medication. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Residents had access to activities that satisfied their chosen lifestyle. EVIDENCE: The home had reviewed the activities provided to residents. They were in the process of employing an activities co-ordinator and their current provision was noted clearly on the notice board. Activities included seniorcise (an exercise programme) and card games. Residents who wish can access a church service that is taken at the home on a monthly basis. Regular meetings are held with the residents in order to gain their views of the home and to give them the opportunity to voice any issues that may have arisen. Few residents were available at the home during the inspection. However a number were observed playing cards or taking advantage of the garden. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 The home has a complaints policy and a policy to protect vulnerable adults from abuse. Some further work is required to the protection of vulnerable adults policy and procedures. EVIDENCE: The home had updated the complaints procedure since the last inspection and the correct details for contacting the CSCI were in place. It was noted that the service user guide required updating however it was the only document that did not contain the necessary information noting the time scale for dealing with complaints. A book was present in the hall of the home for residents to write any complaints in. One had been noted since January of 2005 and the manager had made a written response. The manager and deputy had attended the local authority training course on protecting vulnerable adults from abuse. From the information learnt during the course they had developed a procedure for their staff to follow should an allegation be made. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 25, 26 The home provided adequate communal space for residents. Bathing facilities require further work. The toileting facilities were adequate. EVIDENCE: The inspector toured the communal areas of the home and the grounds. Building work was taking place during this inspection and scaffolding and safety barriers were in place. It is expected that work will be completed by October 2005. A number of the home’s residents and tenants of the nearby sheltered unit have requested a move to the rooms when the refurbishment is complete. In particular demand are the ground floor units as these have access onto the garden with a small patio available. The communal areas were clean and no issues were raised during this inspection. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 12 The lounge area had previously been noted as requiring some work. It is planned that work will begin to redecorate and refurbish the current lounge on the 20th June 2005. New curtains, carpets and furniture will be provided and the room redecorated. As part of the building work a new sluice room and assisted bath will be provided on the first floor. A number of the resident’s rooms are provided with en-suite showers, these are not in use. It was recommended during the last inspection that this provision be reviewed and that the provision of level access showers be considered. No work had been completed on this recommendation. It is required that the home reviews with residents the current provision of showers within these rooms taking into account the needs of the residents. The refurbished single rooms will have level access showers. During the last inspection it was recommended that the home consider the provision of perimeter fencing to increase the security of the building. No decision had been made to provide the additional security. The home has been subject to a burglary since the last inspection, the fourth in four years. One staff member is said to have left the home in part due to their concerns at security. It is required that a further risk assessment take place taking into account the burglaries and the views of the previous staff member. Some work had taken place to the external grounds and a safety rail had been placed to the side of the building where mobility scooters were stored. The remaining area was free of fencing and to one side was a steep grassed verge. The available lighting was less in this area. Given the increasing needs of the residents the fencing and lighting to the rear of the building must be reconsidered. Garden seating had been purchased for use by the residents, it was very light and a risk assessment is required to ensure that the seats are safe to use for people who have mobility problems. A notice to identify the care home had been required at the last inspection, although not in place at the time of this inspection it was confirmed that the item was due to be delivered and put into place. The main entrance had not been identified clearly and a ramp had not been put in place. However a risk assessment had been completed regarding the step into the home. As the needs of those living in the home were changing a ramp to the front door may be required. Both the public liability and building insurance were out of date, November 2004, it is required that the documentation is updated. The manager stated that the insurance cover was provided through Hanover Friends and that the certification had not been forwarded to the home. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 There were adequate staff numbers on duty on the day of the inspection. Further work is required regarding Standards 1, 7, 19, 20, 21, and 29. EVIDENCE: At the time of this inspection the home had only ten residents. Three staff including a senior care was on duty. One waking and one sleep-in staff member were being provided. The manager stated that the staff provision would be reviewed once new residents began to move in. The home has eleven care staff, seven are qualified to NVQ Levels 2 or 3. A number of staff files were sampled and information and documentation to meet the requirements was not present. For example a second reference and current photographs. The home is required to review its current practice and ensure that the recruitment process includes all those items required in The Care Homes Regulations (as amended) 2001. The manager informed the inspector that Hanover Friends will be ensuring the criminal records bureau (CRB) checks will be forwarded to the home, however no date for this was available. The inspector was unable to inspect the CRB forms as they were either not present, photocopies or in one instance transferred from another service. It is required that the CRB checks (original documents) be available for inspection and held at the home. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 14 The home had just received copies of the General Social Care Council code of conduct for social care workers and advised that these would be given to staff as soon as possible. Requirements have been made regarding the Standards 1, 19, 20, 21, and 29 of The National Minimum Standards, Older People 2001. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 37, 38 Further work is required in a number of areas and requirements have been made to reflect this. EVIDENCE: The manager was undertaking the registered managers award and the statement of purpose noted their level of experience in working with older people in residential care. On the day of this inspection the manager was open and keen to consider options and opportunities for the residents. There are regular resident meetings and open door policy encouraging residents and staff to discuss any concerns they may have. The manager and deputy had attended a training course on the provision of supervision and stated that they had now booked the dates for staff Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 16 supervision and that they expected to be able to provide a more regular approach to this need. Whilst the majority of the records seen during this inspection were clear, up to date and signed by either or both staff and residents the staff personnel files required further work to ensure they met the required standard. The staff files sampled evidenced in depth induction training including health and safety and manual handling. The manager and deputy monitored the services provided to residents closely and took responsibility for their actions and those of the staff team. A manager has been employed for the sheltered units and this has greatly reduced the workload of the home manager and enabled her to spend more time with the residents and ensuring their needs are met. Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 2 2 2 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 3 x x x 3 2 3 Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 5(e) Requirement The registered person must ensure that the service users guide contains the timescales for dealing with complaints. The registered person must ensure that a risk assessment for the provision of perimeter fencing is completed, taking into account the previous burglaries and resident and staff views. The registered person must ensure that a risk assessment is completed on the rear garden taking into account the service users needs and safety. The registered person must ensure that a risk assessment is completed on the use of the newly aquired garden seating. The registered person must ensure that a ramp is provided to the front door of the home. The registered person must ensure that all the requirements of Regulation 19 (1)(a)(b)(c) of The Care Homes Regulations (as amended) 2001 are met and that all documents are held on site and open to inspection. The registered person must ensure that the homes public Timescale for action 30th June 2005 30th June 2005 2. 19 23(2)(o) 3. 19 23(2)(o) 30th June 2005 4. 19, 20 23(2)(o) 30th June 2005 31st July 2005 30th June 2005 5. 6. 19,22 29 23(2)(a) (n) 19(1)(a)( b)(c) 7. 37 25(e) 30th June 2005 Page 19 Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 8. 21 23(2)(j) (n) liability insurance and building insurance are up to date and kept up to date. The registered person must ensure that the showers provided in a number of rooms are reviewed with residents and the lack of provision reassessed. A copy of the review and decision to be forwarded to the CSCI. 30th June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stokefield Care Home H58_s36444_Stokefield_v221222_060605_stage4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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