Inspection on 15/11/05 for Stonecroft House Care Home

This inspection was carried out on 15th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stonecroft House Care Home 06/01/09

Stonecroft House Care Home 14/03/08

Stonecroft House Care Home 05/10/06

Stonecroft House Care Home 14/02/06

Stonecroft House Care Home 03/03/05

Stonecroft House Care Home 23/11/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Stonecroft House Care Home Barnetby North Lincolnshire DN38 6DY Lead Inspector Theresa Bryson Unannounced Inspection 15th November 2005 09:30 Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 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 Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 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 Adults 18-65. 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. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stonecroft House Care Home Address Barnetby North Lincolnshire DN38 6DY 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) 01652 688344 01652 688594 Leonard Cheshire Position Vacant Care Home 29 Category(ies) of Physical disability (29), Physical disability over registration, with number 65 years of age (29) of places Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 day care places available in addition to the above Date of last inspection 16th March 2005 Brief Description of the Service: Stonecroft Care Home is situated in a rural position close to the small village of Barnetby and the M180 motorway. The main house is Victorian in style, with a modern extension and set in extensive grounds overlooking the Lincolnshire Wolds. All rooms have views of open countryside and are styled for the individual service users. All bedrooms are single occupancy and eight have en-suite facilities. The home is designed for easy access for those in wheelchairs. The gardens are well maintained and offer a variety of settings to sit and walk in and service users are encouraged to take part in their maintenance. There are a number of different sitting rooms within the home, plus a very large dining area and separate activities room. The home provides care for those with a physical disability from residential category service users through to those with more complex nursing needs. These include 5 places for those with an acquired brain injury. Stonecroft is owned by the Leonard Cheshire Foundation and the local team of Matron, professionally trained nurses, carers and other ancillary staff are supported by a regional and head office team. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one and half days in November 2005. To find out how the home was run and if the people who lived in the home were pleased with the care they got, the inspector spoke to the manager, 8 people who live in the home, 3 relatives and 9 staff. Records kept in the home was also seen to make sure the checks to make sure staff are safe who work in the home had been done and they had been trained to do their job safely. Records were also looked at to make sure the home was safe and checked often. The manager, Mrs.M.Fotherby accompanied the inspector for the visit. What the service does well: The staff looking after the people who live in the home were friendly and knew a lot about each person. They showed dignity and respect to each person when they approached and assisted them through out the day, in a variety of tasks. The information given to each person before entering the home was very detailed and gave an overview of all the services provided. The activities provided were varied and gave people choice to exercise their own abilities and enjoy the company of others in the activities room. The home provides a varied menu and also has the storage space to allow for people who live in the home to have their own meals, such as pizzas and ready meals in the freezers and to plan their daily menus. The people who live in the home and relatives spoken to stated they knew how the complaints process works and were confident in the management team to deal with any problems, if the need arose. The home was clean and staff made regular checks to ensure the environment was safe to live and work in at all times. The home provided competent staff, who had the required checks to ensure they were safe to work with the people who live in the home and that their training was continually updated. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 6 The home manager and her team consult with the people who live there on a regular basis which those people stated makes them feel the building is their home and that they have some say in how it is run. What has improved since the last inspection? What they could do better: The records kept on the people who live in the home need to record how often their care has been evaluated, this is to ensure that all needs are met and care documented is relevant. The records kept for the administration of medicines need to be accurate to show they are given safely and are correct when dispensed. The policy to protect the people who live there from abuse needs to be updated in the section on restraint. This is to ensure the staff are aware of the latest legislation and have clear guidelines to follow. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 7 The staff need to ensure that all equipment used by the people who live in the home is correct for their needs and all furniture and fittings in their individual rooms meet their needs. This will enable the people who live there to live as independently as they can taking into consideration their individual needs. The manager needs to ensure that the snozzelon room is safe to use and made to look a relaxing area for the people who live there to use. The Foundation needs to ensure that all policies and procedures are up to date and they keep to their own schedule of review. This will give staff the latest information to look at when tackling their daily work. 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. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Service users are provided with comprehensive information before entering the home to enable them to make informed choice. Staff are given pre-admission assessments k to enable them to adequately prepare for a person’s admission. EVIDENCE: The service users guide and statement of purpose had been modified since the last inspection and now includes the most up-to-date information on the home. This enables prospective service users to see what services are provided and make informed choice about entering the home. The manager or her designated deputy will complete all pre-admission documentation. There is a quick reference plan to the care plan and the assessment tool used gives an holistic overview of all a service user’s needs. This enables staff to commence a care plan on admission and identifies specific needs of each person. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Service users needs are well monitored using a comprehensive system which enables staff to deliver the appropriate care to each person. EVIDENCE: The care plan documentation provided by the company was comprehensive and gave an holistic overview of each persons needs and how these were to be achieved. There was also paperwork, which gave staff permission to discuss with family or advocates of the service user and a statement on the Data Protection Act. This ensures that service users are aware of their needs, are willing to discuss them and permit staff to share this information. I The 4 care plans tracked showed that specific needs appeared to be addressed and there was follow through written from the daily report sheets to professional visit sheets, monitoring sheets,(for example of bowel habits) and maintenance of specialist equipment such as ventilators and tracheotomy tubes. There was some inconsistency in the documentation used in each care plan, Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 11 which could lead to confusion of staff being able to monitor the care correctly. And there was little written evidence that reviews and evaluations of care take place on a regular basis, which could lead to specific needs not being addressed to the satisfaction of the service user. All service users and relatives spoken to were aware that records are kept on them and most had seen and felt able to contribute to their plans of care. There was no evidence to support that team leaders or the manager reviewed the care plans on a regular basis. This would assist the staff to be aware that all plans of care need to be updated regularly and identify to the manager those staff who may still require extra training to provide the necessary care to service users. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14. 15,16 and 17. Service users have opportunities for personal development and are encouraged to take part in appropriate leisure activities to develop emotionally, exercise their legal and civic rights and be part of the local community. Service users were provided a varied menu to meet their needs and choices. The kitchen had been cleaned effectively making a safe environment for the preparation of food. EVIDENCE: The inspector spoke to the activities organiser who also showed her around the activities room and explained the system in place for the use of volunteers. There is a daily programme of events organised and the area is used 7 days a week. This consists of project work for some service users, group events and individual events. One service user had recently won a cup for his work on a specific project after he had been encouraged to enter a local competition. There was good documented evidence that service users are encouraged to Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 13 use the local community and resources. 4 attend classes at Further Adult education centres and others attend local events and are also encouraged to keep contact and visit family and friends. Service users themselves stated how often they go to their family homes and what events outside the care home they like to attend. Several stated they are encouraged to take up hobbies and there was ample evidence in their own rooms of this. The range covered needlework, model making and computer work. There was good documented evidence kept in the skills and interest folder, physiotherapy and occupational therapy records of the events and interest of individual people. Staff seemed to be aware that personal development should feature highly on specific needs and interests they should encourage service users to adapt to after entering the home. Service users them selves stated to the inspector what they are encouraged to do and how patient staff are in helping them express their individual needs. For example one person stated:” I have recently taken up embroidery again and now an having requests from families to complete small pieces of work” and another stated;” With my new computer I can now access the internet for fact-finding and research projects I am interested in”. The cook of the day showed the inspector around the kitchen and storage area and was able to explain the system of ordering and staff rota system. There had been no changes in suppliers since the last inspection and the cook was happy with their deliveries and quality of food supplied. All checking systems were in place and regular temperature checks recorded. All areas were clean and tidy and the cleaning schedules signed by individual staff members. This ensures the area is safe to prepare food and all care is taken that the quality is of an acceptable standard. Apart from the 4-week cycle of menus service users are encouraged to decide what other supplies they would like stored. This included pizzas, special Chinese and Indian ready meals and special cheeses. Any changes to the menus are recorded on the daily sheets. Service users stated they felt the meals were adequate and portion sizes enough. Any problems previously encountered had been sorted out directly between service users and/or their advocates. There were no problems at the time of the visit. This indicates that service users are treated as individuals and their own tastes and cultural requirements taken in to consideration. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Service users are encouraged to maintain as much independence as their personal conditions will allow and to achieve their own physical and emotional goals. Each person is encouraged and supported to administer their own medication. Failures to complete records correctly could compromise the safety of these arrangements. EVIDENCE: The 4 care plans tracked showed that the service users were supported to achieve their own personal goals for both physical and emotional needs. Some needs were very complex and needed the added support of outside agencies such as occupational and physiotherapist, although the home does provide its own support in these areas. Other healthcare professionals in the community who both visit the home and to whom service users can visit support individuals. Service users spoken to stated they felt there was a good system in place and the home could always meet their needs and were willing to explore all different avenues to help them achieve their personal goals. The administrating of medication was explained by one of the professionally trained nurses. All administration sheets were checked and discrepancies found Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 15 on 4 sheets. The names were identified to the manager at the feedback session. There were also some gaps in the signature boxes on some sheets seen. The staff must be aware that i accurate records must be maintained of medication administered. The reference book provided for staff was out of date by 2-years and needs to be replaced to ensure the most up to date information is available for staff to access. The policy manual for the home states how a safe system can be in place for the administration of medication, the manager must ensure that this is audited on a more frequent basis to ensure all medication is given safely to service users. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. A comprehensive complaints policy was in place for service users and other parties entering the home to see, which detailed how they could make a complaint and the process. Service users and their relatives were aware of how to make a complaint, were confident to do so and believed their concerns would be listened to and acted upon. The restraint policy still needs to be revised; all other issues regarding protecting service users from abuse were in place. EVIDENCE: The complaints statement has been updated since the last inspection and was on display in an area seen by service users and visitors. The whole policy is due to be reviewed in 2007. The complaints log seen showed 1 ongoing complaint, which was being dealt with by the area team, but all documentation appeared to be very detailed. Both staff and service users spoken to appeared to know the process which was in place and were confident in the management team in acting appropriately and dealing with any of their concerns in a professional and efficient manner. Staff appeared to be aware of the policy for the protection of vulnerable adults and had received some in house training on the subject. This will ensure the service users that staff employed by the home are safe to work with this client group and will protect them from abuse. The policy on restraint still has not been revised by the Foundation even though it is detailed as needing revision in 2005. The manager was aware that she needs to provide updated information to all staff to ensure they are safe Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 17 practioners, but policy reviews are dealt with by the Head office team and not in the control of the local home. This matter must therefore be addressed by the Foundation. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,29 and 30. Service users enjoyed a clean, tidy and safe environment. Planning of redecoration and refurbishment of the home was evident to refresh and improve the environment EVIDENCE: The manager was able to produce a programme of maintenance and renewal, which has been put together since the last inspection. This now shows areas to be completed in the next year and gives the service users some encouragement that the Foundation is ensuring that they are living in an environment suitable to their needs and which is safe and well maintained. The inspector was accompanied on a tour of the home by the manager, senior maintenance person and health and safety officer. Some communal areas are looking very “tired”, but these will be addressed once the new programme of redecoration has commenced. Some service users stated they had been given input into the choice of colours for the communal areas. A selection of service users’ rooms were seen and showed individuality in the decor chosen which suited individual tastes and needs. An assessment of furniture and fittings had now been completed in each individual room, to Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 19 ensure staff are aware of what is in each room, whether it needs regular maintenance and what is required for specific needs and what items are the service users own and what has been supplied by the home. An assessment for those requiring locks on doors had been completed and shoed 3 would like them fitted but the rest did not require them. The snozzelon area was very untidy. It needed to be cleaner and all equipment tested to ensure it is safe and in working order. This environment has been provided for service users to relax in, but the inspector found the current condition of the room not conducive to a relaxing environment. Some service users spoken to stated they would use it if it was more welcoming. Since the last inspection the sensory garden had been completed, which has created a relaxing outside area for service users to use. The gardens and grounds at the home are extensive and well maintained. Service users stated they use the areas all year around and all parts of the gardens are accessible to wheelchair users. All areas were free from hazards and ramps are well maintained. The automatic doors in to and out of the home ensure service users can access these areas with out the need for staff to be in attendance if the individuals are safe to use their own transport or can walk independently. The inspector was shown around the laundry by the laundry assistant. This is an airy and light room. All equipment was in working order and the assistant stated there ere enough supplies to ensure linen was available at all times. The home encourages service users to choice their own patterned bed linen and the staff aim to ensure this is always clean and available for them. This has enabled them to have some choice and control over this aspect of their care needs. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34 and 35. The home has a robust system in place for staff recruitment and training. This ensures service users are not put at risk from inadequately trained staff. EVIDENCE: The manager applied for registration with CSCI and has now been interviewed by the CSCI and the final vetting process has yet to be recorded. She also has a valid job description in place, which ensures she is in full knowledge of what the Foundation expects of her as a manager. As a professionally trained nurse she is maintaining her professional portfolio to ensure she is on the “live” nursing and midwifery council register. The training courses she attends will help her to develop the skills to ensure the building is safe, service users are well looked after and staff are safe to work with this client group. The staffing levels have been reviewed since the last inspection and staff stated they were adequate at the time of the inspection to ensure the needs of service users were being met at all times. Other departments also stated that they can cope with the general work allocated to them, but it was fed back to the manager that the activities department and domestic staff would still like to maintain some discussion about their hours as at times it was difficult to maintain a quality service in these areas. Service users did not indicate any problems in the delivery of care provided by any department in the home. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 21 The inspector was given a copy of the training matrix for the home. Some training methods have changed since the last inspection, but staff stated it was early days to give comment on the method now adopted by the Foundation. 35 of staff had obtained NVQ level 2 in the care awards, so the home was gradually reaching the 50 target level. Certificates appeared to also be in place for sessions attended by staff, which covered mandatory training and more service specific training. This ensures they are encouraged to develop the skills to enable them to care for the current needs of all service users. Since the last inspection the administration staff have audited all the staff files and have now ensured that all documentation is present to show they have employed safe practioners. 5 staff files were tracked in depth and showed that all checks had been made to ensure they were safe to work with this client group. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 and 43. The home has a system in place to ensure that the quality of care delivered to service users is provided by supervised staff with a sound knowledge base and that the management team is keeping sound financial control of the home. EVIDENCE: The manager is making good progress with her Registered Manager’s Award, which will give her new skills to enable to run the home efficiently. Service users were able to indicate to the inspector how they ensure their voices are heard and what control they have over not only their personal care but also the environment in which they live. This is completed on a one to one basis, by committee and in open meetings. Minutes were seen of a selection of meetings with staff and service users, with the management team being present and in some cases peer groups on their own. This ensures that service users and staff have some control over their environment and lives. The Foundation also has in place a quality assurance scheme which looks at key preferences in each individual home. Copies of Stonecroft’s indicators were Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 23 given to the inspector. This encompasses all the audits, which take place internally and by regional and head office staff. Ensuring all areas are monitored on a regular basis. The regulation 26 notices are sent to the local CSCI office on a regular basis and are very detailed. The central policy manual was given to the inspector to see, with the index. This showed that a number of polices which should have been reviewed in 2004 and 2005 had not been completed by the Foundation. 5 were dated for review in 2004 and 6 for 2005. The manager must ensure that all staff have updated policies to look at to ensure they are working to the latest legislation and guidance for the safety of the service users and themselves. The business and financial plan had been completed since the last inspection and was valid until March 2006. This shows that the Foundation is maintaining not only financial control, but is looking how to develop the business locally and adhering to its national policies. This is aimed at protecting service users and ensuring they live in a safe environment with well trained and vetted staff. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 2 3 X 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stonecroft House Care Home Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X 3 3 DS0000002805.V266199.R01.S.doc Version 5.0 Page 25 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 YA6 Regulation 15.2. Requirement The registered person must ensure that reviews on in house care programme are completed. (Previous time scale of 20/02/04 not met). The registered person must ensure that all administration records for medication are accurate and there is good stock control. The registered person must revise the home’s restraint policy/procedure to include reference to Dept of Health guidance. (Previous time scale of 20/0204 not met). The registered person must ensure that all equipment in the Snozzelon room is safe and the area always ready for the use of service users. The registered person must ensure that all policies and procedures are up dated. (Previous time scale of 30/08/05 not met). Timescale for action 30/01/06 2 YA20 13.2. 30/01/06 3 YA23 13.6. 30/01/06 4 YA29 23.2.c. 30/01/06 5 YA40 24.1.a. 30/03/06 Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 26 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 Refer to Standard YA24 YA32 YA37 Good Practice Recommendations The provision of a cleaning schedule for domestic staff would ensure that all areas of the home are maintained to the same high standard on a regular basis. The manager is aware of the deadline for completion of NVA training for staff. The manager is aware of the deadline to complete her Registered manager’s award. Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Stonecroft House Care Home DS0000002805.V266199.R01.S.doc Version 5.0 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!