Inspection on 04/04/07 for Stonecross Lane Care Home

This inspection was carried out on 4th April 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Stonecross Lane Care Home 31 - 33 Stonecross Lane Mansfield Nottinghamshire NG19 7DH Lead Inspector Joanna Carrington Key Unannounced Inspection 4th April 2007 10:00 Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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 Stonecross Lane Care Home DS0000068831.V333584.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 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. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stonecross Lane Care Home Address 31 - 33 Stonecross Lane Mansfield Nottinghamshire NG19 7DH 01623 621873 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) Nottinghamshire County Council Mrs Judith Mary Wagstaff Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nottinghamshire County Council is registered to provide accommodation and personal care to people at Stonecross Lane Care Home, 31 - 33 Stonecross Lane, Mansfield, Nottinghamshire, NG19 7DH whose primary care needs fall within the following numbers and category: Learning Disability (LD) - 12. NA Date of last inspection Brief Description of the Service: Stonecross Lane is a care home registered to provide support and accommodation for up to twelve adults with a learning disability. Nottinghamshire County Council has recently become the registered provider for this service. The home is located in a residential area close to Mansfield town centre and its amenities. The home consists of two purpose built bungalows, within the same grounds, each accommodating six residents. All of the bedrooms are single; none are en-suite. People with associated physical disabilities are also accommodated at the home, and specialised equipment is available to meet individual needs. There are accessible and well-maintained gardens and the home has its own vehicle. The fees for the home range from £335 to £379 per week. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the home’s first key inspection since Nottinghamshire County Council became the registered provider on 1st November 2006. The inspection took place over eight hours on 4th April 2007. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking their care by checking their records, discussion with staff and observations of care practice. Although there was some interaction with residents, due to the complex communication needs of residents the inspector was not equipped to speak with them directly about the care service. Staff files were also examined to make sure the staff team is trained to do their job and that checks are carried out on staff members before they are employed. A partial tour of the premises also took place in order to inspect environmental standards. Three staff members and a visiting reviewing officer were spoken with and the registered manager was available for discussion and feedback throughout the inspection. Judgements about a service are also made from information that is received about the service before an inspection. This includes notifications and monthly inspection reports by the registered provider. The pre-inspection questionnaire was not returned, however before the inspection took place. What the service does well: The Statement of Purpose and Service User Guide have been updated, which means that prospective residents and their representatives can make an informed choice about moving to the home. The needs of prospective residents are assessed in order to make sure that the home is suitable in meeting their needs. The staff team have a good understanding of residents’ individual needs and level of support, which is accurately reflected in care plans that cover emotional, health and personal care needs of residents. Care plans are regularly reviewed so to make sure any changes in how support is given can be identified. Healthcare professionals are called on when it becomes necessary in maintaining a resident’s health and wellbeing. The staff team have a good awareness of the individual communication needs of residents and use tools such as pictures and referential items to enable residents to exercise choices and make decisions in their lives. The staff team are clearly committed to promoting residents’ quality of life through access to the community, participation in fulfilling activities and enabling contact with family and friends. Meals are healthy, varied and nutritious. Residents are treated with dignity and respect. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 6 The bungalows are well maintained and kept clean and tidy. What has improved since the last inspection? What they could do better: Now that care officers have been trained in administering medicines it should now be considered if care officers can be trained and delegated the task of administering medication that are specialised, invasive techniques, for example rectal diazepam for seizures. Only qualified nurses are currently trained to give this medication but they are not always leading a shift. This will make the staff team more effective in meeting the needs of residents. Although there are good risk assessments in place that identify measures for promoting safety in daily routines and also with residents’ chosen activities, to ensure that these measures remain appropriate these risk assessments must be regularly reviewed. This process will also aid in identifying any progress in developing skills and independence. Staffing levels needs to be reviewed to make sure that they are appropriate to the needs of residents. Some of the residents have not had their needs fully assessed by the placing authority for a very long time. This will be an important part of the process in ensuring that the funding of placements is relevant to the provision of staffing in the home. To ensure the protection of residents from abuse the staff team need further awareness of the whistle blowing policy and of their responsibilities to alert the registered manager of all allegations of abuse. The use of sound monitors for monitoring seizures must be referred to in a relevant care plan because they can potentially be an invasion of residents’ privacy if not used for the sole purpose identified. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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 Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place that ensure the home is suitable in meeting prospective residents’ needs. EVIDENCE: The Statement of Purpose and Service User Guide were updated in March 2007, which means prospective residents and their relatives / representatives are able to make an informed choice about moving to the home. On the files of the residents’ case tracked there was evidence of a comprehensive needs assessment carried out by a staff member at the home, which is carried out annually. This is in line with the policy and procedures of the previous registered provider. This assessment is to identify the individual needs of residents and then forms the basis of the care plans. There have been no new admissions to the service since the home has been newly registered. The home’s admission procedure includes obtaining the placing authority’s community care assessment in order to decide whether the home would be suitable. The placing authority’s community care assessments were not located during the inspection for the residents that were case tracked because they have not had their needs fully assessed by the placing authority for a very long time. (Refer to outcome area Staffing) Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. There are good arrangements in place for ensuring that individuals needs and choices are met. Risk assessments enable residents to access their chosen activities safely, however promoting individuals’ independence may be compromised if risk assessments are not kept under review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three residents case tracked have care plans that cover their social, emotional, health and personal care needs. These care plans are evaluated approximately every three to four months to ensure that needs are met and to make amendments to care plans if necessary. Annual review meetings are also held in which professionals involved in that individual’s care and relatives are invited along to discuss the placement and the support given. On the day of the inspection a review was taking place for one of the residents’ case tracked. There are risk assessments in place accompanying care plans, that identify ways individuals’ can participate in activities and in accessing the community such as going out on the bus unaided and going out in the garden. Some of Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 11 the risk assessments seen have not been reviewed for a very long time. A risk assessment for access to the kitchen was devised in 2002. Reviewing this risk assessment will ensure that the measures for keeping the resident safe are still appropriate. Staff members spoken with demonstrated an understanding of residents’ needs, including their communication needs, which reflected what is written in care plans. All residents case tracked have information in their care plan on how they express themselves if for example, they are happy, frightened and how they say yes or no. The daily records seen indicate that residents are able to make choices, for example when they want a bath, and when they want a lie in, in the morning. Staff spoken with explained how residents are supported to make choices in their everyday lives. Some residents’ are shown items while others use picture boards and photographs and some signs and symbols. There is also day-to day information in bungalows about residents’ needs and likes and dislikes, which is easily accessible for temporary bank and agency staff. An advocacy service in the area has now been able to provide support to some of the residents. This provides residents with an independent person to speak up on their behalf and in their best interests. The care plans are still written in the format of the previous registered provider. (Refer to outcome area Conduct and Management.) Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a commitment from the staff team in promoting residents’ rights and enabling residents to experience a fulfilling quality lifestyle. EVIDENCE: Most residents attend day centres during the week, and there are various day centres that are used, depending on residents’ needs and preferences. On the day of the inspection for those residents not attending day centre they went out to lunch with staff. Staff spoken with reported that there are regular trips out into the community with residents, for example to the pub or shopping in town, which was reported in the daily records seen. A staff member reported that at the weekend six residents went out for tea. These activities have to be planned in advance so that additional staffing can be put on. Every Sunday an additional staff member is on shift so that residents can go to Church and there are residents that attend the Faith and Light group each month. This was noted in the staff rotas looked at. A staff member reported that some residents have chosen to return to Scarborough for their holiday later this year. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 13 Care plans and daily records indicate that contact with family and friends is promoted and maintained. There are regular visits by family members and a staff member spoken with confirmed that visitors are always welcome. Menu plans and menu records show that residents are provided with a healthy, various and nutritious diet, with alternative meals always on offer. On the evening of the inspection the planned meal was chicken curry and rice. Staff were observed interacting with residents in a respectful and meaningful manner. Staff spoken with gave good examples on how they ensure residents’ rights are upheld, such as making sure residents are asked what they want to do rather than assume, and always closing the door when assisting with intimate care. On a tour of the premises a sound monitor was seen in the bedroom for one of the residents’ case tracked. It was explained that this is for monitoring seizures at night, but there was no mention of this in the care plan or risk assessment. This is recommended so that it is clearly specified as to when this monitor is used. This is to balance the need to use this equipment with the resident’s right to privacy. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place for ensuring residents receive personal support in the way they prefer and require and for ensuring health care needs are met. EVIDENCE: Staff spoken with described the personal preferences of residents’ with how their personal care is given, which was reflected in the relevant care plans, for example, having hair done nicely and “appreciating a bath in the evenings for relaxation.” There are care plans for ‘promoting good health’ paying attention to regular visits to the dentist, podiatrist and opticians and well-man and well-woman clinics. All appointments are recorded. Daily records indicate that specialist professionals such as clinical psychologists, occupational therapists, speech and language therapists and physiotherapists are accessed when necessary. The reviewing officer praised the staff at the home for their prompt action in seeking support from relevant professionals. Evidence on staff files indicates that in addition to the qualified nurses at the home, care officers are now trained in administering medication. Staff spoken with confirmed that they are then supervised for three months before a Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 15 competency assessment is carried out. Only then can care staff take on this responsibility. This makes the staff team more effective because qualified nurses do not always run the shifts. Only the qualified nurses are currently able to administer emergency epilepsy medication such as rectal diazepam, which is an invasive technique. When qualified nurses are not on shift if a resident was to have a series of seizures an ambulance would need to be called. It is recommended that consideration be given in terms of risk to residents as to whether care officers can also be ‘delegated’ this task. An appropriate health care professional would need to provide training. The storage of medicines is organised and the instructions for administration are clear and records show that medicines are administered as prescribed. The quantities of tablets are now being monitored closely with a running record kept on the MAR each day of what tablets are remaining. All medicines audited had the correct quantities of medication as stated on the medication administration record (MAR). It is recommended that when an ‘as required’ medicine is not supplied that cycle a record is made on the current MAR of the remaining quantity in the home. This will ensure all stocks of medication are accounted for and can be easily monitored. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. The complaints procedure assures residents that their views and concerns are listened to. Service users are not fully protected from abuse unless all staff members understand their responsibilities in accordance with Safeguarding Adults policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An accessible version of the new registered provider’s Complaints Procedure is displayed in both bungalows. It is presented using symbols so to enable people with learning difficulties to understand it. There have been no complaints made since the home has been re-registered. Staff spoken with demonstrated an understanding of the purpose of the Complaints Procedure, for ensuring expressed concerns are acted on. There have been no disclosures or allegations of abuse since the home has been newly registered. A copy of the Safeguarding Adults procedures is available to all staff located in the office. Staff members spoken with are aware of these procedures, which are to be followed in the event of an allegation of abuse however there was a lack of understanding regarding whistle blowing and the duty of care to alert the registered manager of any suspicion of abuse. This is a learning need, which must be addressed. Training records indicate that training in adult protection is overdue for staff. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a hygienic and safe and comfortable home. EVIDENCE: On a partial tour of the premises it is evident that the home is kept clean and tidy. There is a daily, weekly and monthly chore list to ensure that the staff team carry out all necessary cleaning tasks. Laundry facilities are sited well away from food and washing machines have sluicing facilities and the ability to meet disinfection standards. All bathrooms and toilets had hand soap and paper towels in them, which is important for good hygiene. The décor of the home overall is well maintained and the lounge areas are pleasantly decorated with a light and airy feel. The conservatories provide more communal space for residents to relax in. The bedrooms seen are personalised to suit individuals’ taste, with their chosen belongings such as photos, pictures and posters. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices and training arrangements ensure the safety and protection of residents, however staffing levels need reviewing to ensure they are appropriate to the needs of residents. EVIDENCE: All three staff files examined contain two written references and evidence of a satisfactory criminal record bureau check, which were obtained before each staff member commenced their employment. On all three staff files selected there was evidence that food hygiene, moving and handling, first aid and fire safety courses have been attended. The staff team are currently undergoing comprehensive three day training in managing aggression. Staff spoken with confirmed that this has been helpful and are impressed so far with the amount of training they have been on since the home has been re-registered. The new staff member is due to go on learning disability award framework (LDAF) induction and foundation training. The registered manager reported that the staff team is down by three whole time equivalent posts. Bank and agency staff are being used to cover shifts and staff spoken with confirmed that the same agency staff are being used, which gives residents the stability that they need. The set staffing level is two Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 19 staff in each bungalow. In the last three weeks there have been two occasions in the evening when only three staff have been on shift. Given the complex needs of the residents this is not a safe level. Additional funding has been made available to two residents following their community care reviews and staff spoken with confirmed that this has made a positive difference, however it is additional to the set establishment of hours. Prior to the registration of this home, staffing levels has been an ongoing problem at the home. There have been protection issues at one of the bungalows where one resident has assaulted other residents. A community nurse that carried out an assessment of this resident in response to an adult protection referral reported that staff need to be more aware of where this resident is. This is not always achievable with only two staff members on a shift particularly around dinnertime, when a staff member is preparing the meal. On the day of the inspection the lounge area in this bungalow was observed not to have a staff member supervising residents for a significant length of time. The registered manager reported that funding has been agreed for employing a person whose main responsibility will be driving residents to and from day centre. It is recognised that this will solve the staffing problems during the week, as this is a constant job with residents starting and finishing their day services at different times. This has caused problems for those residents that are not at the day centre on certain days and therefore require support. Residents in one bungalow have to go to the other bungalow to be supervised because there is not enough staff. As stated in Outcome area, Choice of Home, some residents have not had their needs assessed by the placing authority for a long time. This exercise will play a key part in reviewing whether staffing levels at the home are appropriate in meeting the needs of residents. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and safety and the home are generally managed well and effective quality monitoring aims to ensure the home is run in residents’ best interests. However, the lack of policies and procedures in place compromises this. EVIDENCE: The fire log shows that all the required fire safety testing has been undertaken and the fire risk assessment has been reviewed and updated. The last fire drill was in August 2006 so this is now overdue. Fridge and freezer temperatures are recorded on a daily basis. The registered provider in accordance with Regulation 26 of the Care Homes Regulations 2001 is carrying out monthly inspection visits. A report supplied to the Commission confirms that electrical testing is up to date and that there are measures in place for the prevention of legionella. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 21 Advocacy Alliance are involved in seeking the views of residents and in implementing the Nottinghamshire initiative, ‘The Quality Tree’, which provides tools that involve residents with a learning disability in reviewing and monitoring the quality of a service. There have been no results as yet so this will be examined at the next inspection. The home has been registered with Nottinghamshire County Council for six months. The IT system at the home is still not set up and therefore the home is not on line. This is causing difficulties with communication and with certain practices, such as recruitment and applying for training because these things are done on line. The registered manager has to go to another service to do these things. The staff team do not have access to all of the policies and procedures as these are also on line and hard copies have not been made available. The registered provider must also ensure that all policies and procedures are applicable to the home as the current policies seen are geared more towards short break services. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 1 3 X Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NA 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 YA9 Regulation 15 Requirement Risk assessments must be kept under review, to ensure that measures in place remain appropriate, and to promote residents’ skills and independence. Make sure all staff members are trained in understanding whistle blowing and their responsibilities to alert suspicions and allegations of abuse. This will help protect residents from abuse. Review staffing levels to ensure they are appropriate to the assessed needs of residents. Timescale for action 01/06/07 2 YA23 13 01/07/07 3 YA33 19 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA16 YA20 Good Practice Recommendations Include the use of sound monitors in the relevant care plan, paying attention to residents’ right to privacy. Consider delegating the task of administering emergency DS0000068831.V333584.R01.S.doc Version 5.2 Page 24 Stonecross Lane Care Home 3 YA20 4 YA40 epilepsy medication to care officers, through the appropriate training by a healthcare professional. This is to ensure the healthcare needs of residents are met. Carry forward onto the current medication administration record any remaining quantities of medication from the previous cycle. (This is relevant to ‘as required’ medication) This will ensure all quantities of medicines are accounted for in the home and can be monitored. Make sure the policies and procedures for the home are relevant to the service and its statement of purpose, and that these are accessible to all staff. Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Stonecross Lane Care Home DS0000068831.V333584.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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