Inspection on 21/11/05 for Stonehill House

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Stonehill House 10/07/07

Stonehill House 28/12/06

Stonehill House 22/02/06

Stonehill House 10/02/05

Stonehill House 26/10/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Stonehill House 106 Churchway Haddenham Bucks HP17 8DT Lead Inspector Mrs Caroline Roberts Unannounced Inspection 21st November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stonehill House DS0000023025.V267868.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 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. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stonehill House Address 106 Churchway Haddenham Bucks HP17 8DT 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) 01844 290028 abbeyfield.haddenham@ukonline.co.uk The Abbeyfield (Haddenham) Society Limited Mrs Lindsey McGibbon Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: Stonehill House is a residential home, which is owned and managed by The Abbeyfield Society. It is registered to provide residential care for up to 11 elderly people. The home is situated in the active rural village of Haddenham and is close to local amenities, which include shops, a library, pharmacy dental practice and Health Centre. Transport links are available to the towns of Aylesbury and Thame, as well as Oxford City. Stonehill House offers accommodation within a converted and extended home similar in style to nearby properties. There are pleasant accessible gardens to the property. Accommodation is offered in single rooms some of which have an en suite facility. All service users are registered with the local GP Practice and weekly visits are made to the home by GP’s and support is provided from the District Nursing Team. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Each care home that is registered with the Commission for Social Care Inspection, receives one announced and one unannounced inspection each year and further additional visits as necessary. All inspections, both announced and unannounced are followed by a written report, which eventually become public documents. It is a requirement that inspection reports are made available within the home. This inspection was unannounced and took place on the 21st November over a three-hour period. The inspector present was Mrs Caroline Roberts. The inspection consisted of meeting with Residents and staff, viewing records and documents pertaining to the provision of care and the running of the home. The inspector toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a further number from the doorway. The homes manager, Mrs Lindsey McGibbon, met the inspector on her arrival, and was present throughout the course of the inspection. The inspector discussed the inspection findings with Mrs McGibbon prior to leaving the home. Throughout the course of the inspection staff were polite, helpful and welcoming towards the inspector. The inspector would like to thank staff for their assistance and co-operation throughout the inspection, and would like to thank the residents for allowing her into their home. What the service does well: What has improved since the last inspection? What they could do better: Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 6 All staff should have sit-down supervision with the manager at least six times per year, so that staff are fully supported in their work. The manager needs to ensure that all potential residents have their needs assessed prior to admission, to ensure the home can meet the identified needs. This process needs to be fully documented. The registered manager needs to ensure that she maintains paperwork relating to the day-to-day management of the home. Designated management hours will aid this task. Training records must be fully maintained. The manager must ensure that staff are appropriately trained, to undertake their duties fully. The home would benefit from a copy of The Royal Pharmaceutical Society Medication Guidelines for care homes, as shortfalls were identified during this inspection. 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. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 3 Without undertaking a pre-admission assessment fully the home may admit someone for whom they cannot meet the needs. EVIDENCE: At the time of the inspection the home had one vacancy, the manager stated that this had been reserved for a potential resident who was due to move in to the home at the beginning of December, the manager stated that a preadmission assessment had been undertaken unfortunately no paperwork was available in the form of a pre-admission assessment to evidence this. The manager was reminded that the home is required to undertake a preadmission assessment to ensure that they can meet the needs of any potential resident prior to admission. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 9 The home does have a medication policy however; this needs updating, the process of medication administration needs further development and monitoring to ensure that residents are not put at risk by staff not following correct guidelines. EVIDENCE: The home has a medication policy however; this needs reviewing to reflect what actions staff need to take in the event of a medication error. Medication administration records were viewed this highlighted that staff are handwriting medication administration advice details onto the mar sheets without evidence of the original prescription, this was discussed with the manager. One member of staff was observed administering medication to a resident, this was not done in line with good practice or indeed medication administration guidelines; the member of staff popped the tablets from the dossett box onto her hand then gave to the resident. Medication is stored appropriately. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 10 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 the following standard(s): EVIDENCE: Not inspected during this inspection. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 11 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 the following standard(s): EVIDENCE: Not inspected during this inspection. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19 The standard of the environment within this home is good, providing Residents with an attractive, safe and homely place to live. EVIDENCE: Stonehill House is located on the main street, close to the centre of Haddenham. The home provides a pleasant lounge and dining room for the communal use of residents. The home is reasonably maintained, clean and decorated to a good standard. Residents spoken with said that it was a comfortable and pleasant place to live. The home is well lit with natural light and warm. Furnishings are domestic in character. The home was adequately heated, and low surface temperature covers have been fitted to the radiators. The home is equipped with mobility aids; a lift provides access to the first floor. Call bell systems are in place. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 13 Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staffing deployment in the home requires careful consideration to ensure that resident’s needs are met and the manager can undertake her duties fully within agreed hours. The home does not have a high turnover of staff, the manager is aware of what is expected of her in relation to safe recruitment practices, one error made earlier in the year is not the usual practice for this home. Training records are not up to date, a staff development plan was not available, without adequate training staff are not able to fulfil the aims of the home and meet the changing needs of the residents. EVIDENCE: At the time of the inspection, two staff were on duty the manager and one carer. The rota was unable to be examined as the home do not have a weekly rota which reflects actual worked hours and by whom, a diary is used staff write what hours they have worked, this did not reflect actual worked hours or give any indication of cover needed for sickness and leave. The manager works everyday as part of the care team and needs to have designated supernumery hours in order to undertake management duties. (Requirement made). Due to the resident numbers throughout the waking day the home should have no less that two staff on duty, at night the home has one waking night staff and one on call, this is quite often the manager who lives on site. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 15 The recruitment files for three staff were viewed, two contained all of the information as required under Regulation 19(1) Schedule 2 The Care Homes Regulations 2001, one identified that a carer employed at the home had no application form, no references and a CRB date after the employment date, the manager was asked to look into this matter at once. The training profiles for staff were viewed this identified that they had not been maintained and provided out of date information. Training provided such as care planning did not indicate course content, duration or who facilitated. Mandatory training such as moving and handling, first aid, and food hygiene, records have not been updated according to the records moving and handling training has not been provided since October 2003, the manager confirmed that staff have received update training but that she had not had the time to update the records, the manager has agreed to update the records and provide the certificates at the next inspection. Medication training has been provided however, it is difficult to ascertain if this is an accredited training, again no course content is included on the certificate, and it does not detail who facilitated the course. The certificate is signed by the responsible person for the home. A requirement is made that the manager makes arrangements for all staff to undertake an accredited safe handling and medication administration course. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36, The manager is qualified and competent to manage the home however, she needs designated management time to be able to discharge her duties fully. Care staff do not receive individual supervisions, therefore they are not able to share practice issues and discuss development needs. EVIDENCE: The manager is clearly very supportive of the staff team on an everyday basis. Her knowledge of the residents needs was evident throughout the course of the inspection. Due to the amount of time the manager has to cover the care rota the management tasks have taken a back seat, areas such as: Rotas Training records Projected training plans Individual supervisions Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 17 Generic Risk Assessments Regulation 37 Notifications Medication record monitoring It is hoped that once designated management time has been established, the manager will be able to undertake her duties fully. Staff have not received formal supervision, the manager states this is due to not having the time. Progress with this will be monitored at the next inspection. (A requirement is served) A member of the care staff on the afternoon shift had taken a resident to the doctors in her own car, it transpired that she was not covered for business use on her insurance, the manager was unaware that she needed to ensure staff had the correct insurance if they were to use their cars for business use. The manager and the inspector were unable to use the office to view paperwork and discuss issues of a confidential nature due to the room being the size of a small cupboard, a room is available upstairs that was an overnight room, it is recommended that this room becomes an office, that the manager can then use to conduct resident reviews, staff supervisions and any meeting which requires privacy. The use of the residents dining area is not appropriate. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 1 X x Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP36 Regulation 18(2) Requirement The registered manager is to ensure that all care staff receive formal; supervision at least 6 times per year. To commence by February 2006. The provider is to review the managers working hours to ensure she has dedicated management time allocated to undertake her duties fully. The inspector is to be informed of the outcome of this review in writing. The registered manager is required to maintain a copy of the rota of persons working at the home, and a record of whether the roster was actually worked. The registered manager is required to arrange accredited medication training for all staff that take part in the administration of medications. The registered manager is required to review and update the homes medication policy, in line with Royal Pharmaceutical guidelines. DS0000023025.V267868.R01.S.doc Timescale for action 01/02/06 2 OP27 18(1) 01/02/06 3 OP27 17(2) Schedule 4(7) 01/01/06 4 OP9 13(2) 10(1) 01/06/06 5 OP9 13(2) 01/02/06 Stonehill House Version 5.0 Page 20 6 OP3 14(1) 7 OP21 23.2b/d The registered manager is required to ensure that any potential resident has their needs fully assessed prior to moving into the home. Details of this assessment are to be maintained. Complete the refurbishment of the toilet and bathroom areas. (Original compliance date 30/6/05) 15/12/05 01/03/06 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 31 Good Practice Recommendations It is recommended that the manager review the office location and facilities. Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Stonehill House DS0000023025.V267868.R01.S.doc Version 5.0 Page 22 - 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. 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