Inspection on 20/01/06 for Stoneleigh

This inspection was carried out on 20th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stoneleigh 21/05/07

Stoneleigh 26/07/05

Stoneleigh 25/02/05

Stoneleigh 24/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 Stoneleigh Stoneleigh Care Homes Ltd 166-168 Stourbridge Road Holly Hall Dudley West Midlands DY1 2ER Lead Inspector Unannounced Inspection 20th January 2006 10:00 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stoneleigh Address 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) Stoneleigh Care Homes Ltd 166-168 Stourbridge Road Holly Hall Dudley West Midlands DY1 2ER 01384 235590 01384 353830 Mr Sanjiv Jain Mrs Sonu Jain Mrs Sonu Jain Care Home 18 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Stoneleigh House is situated on the main Holly Hall Road, between Dudley and the Merry Hill Centre. The home has limited off road parking, and offers a rear garden/patio area. The home is accessible by public transport and is close to local shops and amenities. The majority of rooms are single occupancy and do not offer en-suite facilities. The home offers two main lounges on the ground floor and separate dining rooms are also available. The property consists of two Victorian houses converted into one dwelling but each retaining its own facilities and character. The home does not have a passenger lift, but does offer ground floor accommodation. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced meaning that prior notification was not given and the homes’ staff and management were not able to prepare. One Inspector conducted the inspection, which began at 10.00am and finished at 6.45pm. The Manager / proprietor and her husband who is joint proprietor supported the inspection process throughout the day. The plan for the inspection was to assess those key National Minimum Standards that were not assessed at the previous inspection including progress made towards meeting related previous requirements issued for improvement. Although it extended the inspection day progress towards some but not all additional previous requirements were also assessed. The Inspector was also able to talk to staff including the Deputy Manager and interviewed a staff member in detail about practice within the home. The Inspector also talked to one service user in private about her experience of the home as well as chatting to other service users generally during the day. The Inspector upon arrival was able to observe breakfast served to two service users who had chosen to rise late. The Inspector also toured the premises and assessed policies and care records. No notices detailing the need for immediate improvement were issued at this inspection. What the service does well: The home is clean and infection control procedures are good with staff understanding measures in place to prevent the spread of infection. There is a rolling programme of service maintenance, which is controlled well ensuring that the structure of the home and equipment in it is as safe, as possible. An ongoing improvement in systems has lead to a marked decrease in the number of accidents occurring to service users. Accidents have decreased according to records from 23 in 2004 to 8 in 2005. There is also a well-managed training programme for staff that appreciates and benefit from the training available. This supports staff to gain the required knowledge and skills to meet service users needs. Medication is generally well managed with there being one requirement for improvement arising from this inspection. Meals and nutrition are well managed too with a service user saying that she enjoys the meals. Menus are well planned and adhered to with records kept accounting for any deviation from the menu. Dieticians have supported the home and a service user previously assessed as at nutritional risk has put on an appropriate amount of weight. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 6 There is a regular programme of meetings taking place to consult with service users and these meetings are recorded in detail. A service user told the Inspector that ‘this is a nice place’ and couldn’t think of any aspect that requires improvement. A staff member said ‘I love it’. What has improved since the last inspection? What they could do better: The frequency of and evidencing of Fire Drills must improve to prepare staff for what to do in the event of a fire. Fire Drills are not being carried out sufficiently and are not planned to ensure that all staff including night staff have this experience. The manager said that these are carried out at the end of staff meetings but as staff meetings are also not evidenced this is not sufficient. This practice if taking place also does not enable staff to practice under realistic conditions as more staff and less service users are present at staff meetings than would be usual. The last fire drill was recorded as taking place in September 2004. It is a requirement from the previous inspection to ensure that staff meetings are held regularly and at regular intervals. This has not been met. There is Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 7 evidence of only one staff meeting (January 2006) since the last inspection in July 2005. Records of the meeting process must be kept. There is a good staff-training programme in place for existing staff. The manager is providing in house induction information for new staff. Induction training is now available to the required standard but new staff are not starting and completing it to the required standard within the appropriate time frame. This means that untrained staffs are unnecessarily supporting service users. Levels of activity that meet the wishes and preferences of service users must improve. There was evidence at this inspection of insufficient activity and insufficient access to the community for service users. In addition a holiday was not provided in 2005. The Inspector was told that service users did not want a holiday but there is no evidence of this. Resident meeting records evidence ideas being given by service users for holidays in 2005. Discussion with a service user showed that she enjoys holidays, would have wanted to go on holiday, didn’t know why they hadn’t gone on holiday and is looking forward to going on holiday this coming year. Records also indicate that service users do not wish to have bedroom door keys. During discussion with a service user she clearly requested a key as she told the Inspector that new clothes go missing from her bedroom. The Manager agreed to treat this feedback as a complaint by recording, investigating and feeding back the outcomes to the Commission for Social Care Inspection and other agencies where and if appropriate. A refurbishment programme is not in place with the proprietor manager saying that improvements are made as and when they are needed. She is aware that the dining room now requires redecoration and said that its improvement is imminent. The commissioned water report has identified several high priority improvements required. These had not been acted upon but remedial work required was booked during the inspection day for the following week 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. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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): EVIDENCE: These Standards were not assessed at this inspection. There have been no new admissions or discharges to or from the home. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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): EVIDENCE: These Standards were not assessed at this inspection. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 11 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): 12, 13, 14, 16, 17 Systems are not sufficiently developed to support service users to engage in appropriate activities. Access to the local community from the home is limited. A respectful approach by staff ensures that service users rights and responsibilities are generally recognised on a day-to-day basis. But an improvement in some systems is required to underpin this e.g. through the better provision of holidays, keys, and activities. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Most service users attend traditional day centre settings full time Monday to Friday. Some attend part time and three service users do not have any formal day care. There is one activity timetable for the week but no evidence that this is adhered to or that it meets individuals assessed interests and wishes. Planned morning activities are all sedentary activities. The plan for every afternoon of the week for all service users including weekends is ‘relaxation’ and sedentary in house activities are again planned for every evening. The schedule shows a plan to go to the pub two evenings per week and church on Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 12 a Sunday. Visits to the pub are not taking place twice per week. There was evidence of 5 service users going to the pub on May 28th 2005 but this is insufficient. There is evidence of one service user attending church on Sundays sometimes twice in one day as he is able to attend independently but again for the three weeks prior to this inspection other than day care he had been nowhere else. There is no evidence that those service users who require support to attend do so in accordance with the schedule. Care records were assessed for five service users and activity levels and access to the community is insufficient. The records showed that one service user between November 2004 and May 2005 went shopping three times. Another service user between January and May 2005 had been shopping twice with no other outing into the community evidenced. Another younger service user had not been out for the first three weeks of January prior to this inspection. Records for a further service user showed that again for the first three weeks of January prior to this inspection she ‘relaxed in her room and watched TV’. Discussion with staff showed that some service users had been on some group trips during the year e.g. to shows and musicals but records could not demonstrate who took part and when. A further service user spoken to however indicated that there is enough to do and that she is not bored. A holiday was not provided in 2005. The Inspector was told that service users did not want a holiday but there is no evidence of this. Resident meeting records evidence ideas being given by service users for holidays in 2005. Discussion with a service user showed that she enjoys holidays, would have wanted to go on holiday, didn’t know why they hadn’t gone on holiday and is looking forward to going on holiday this coming year. On a day-to-day basis service users rights and responsibilities are respected. The Inspector observed service users who had chosen to rise late, being offered breakfast choices and their choices being respected. Service users could choose where to sit for breakfast with some choosing to sit in different rooms. Staff were observed to knock on doors and address service users in accordance with their recorded wishes. Discussion with staff and service users in conjunction with observation showed the Inspector that service users where they wish to are encouraged to take part in some domestic tasks such as laying tables, emptying bins and carrying personal laundry to be washed. But this has not been included in plans of care as required previously. A service user confirmed that she is given her personal mail to open and wishes in respect of mail management are recorded in plans of care. Service users are able to spend time alone should they wish to. Areas for improvement include the need to ensure that the contract between the home and the service user includes rules on alcohol and drugs and to review previous recorded decisions about service users holding keys to their rooms. Service users are recorded as not wanting keys. Discussion with one service user indicated that at the time of this inspection she was keen to have a key for her bedroom as she said that her clothes are going missing from her Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 13 wardrobe. The Manager has been asked to regard this as a complaint and to investigate accordingly. Service users said that they like the meals and have sufficient to eat. Stocks of food are plentiful including fresh fruit and vegetables. A rolling menu is in place with records kept to account for deviations from the menu including deviations as a result of service users choice and requests. Systems are in place to identify and respond to service users at nutritional risk and outcomes for these service users are good with one service user who is at particular nutritional risk having been supported to appropriately gain weight. Discussion with a staff member showed the staff member to be aware of this particular service users nutritional need. Staff are also aware of individual service users likes and dislikes in respect of food and meals which are also recorded. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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, 20 Service users receive personal support in the way they prefer and require. Service users are generally protected by the homes policies and procedures for dealing with medicines but better written guidance for the administration of medication prescribed as ‘as required’ will more fully protect service users from the risk of over or under medication. EVIDENCE: Care plans provide good detail to guide staff in the appropriate provision of personal care to service users. The written guidance considers the abilities and preferences of the service users. A staff member said that the care plans were helpful and she verbally demonstrated a good understanding of privacy and dignity issues and how to maintain these in practice for service users. A service user confirmed that staff support her personal care in a manner that she finds acceptable. Resident meeting minutes showed that residents are well consulted and minutes from 2005 show residents to have been individually consulted as to their preferred rising and retiring times. Observation for two service users shows these recorded preferences are being adhered to. A key worker system is in place. Both the staff and service user spoken to demonstrate that they had a good grasp of the role and function of key workers. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 15 Medication systems in place generally support good practice. Records were comprehensively completed to evidence no gaps in the administration of prescribed medications. Staff are currently undertaking accredited distance learning medication training and a new staff member who is doing the training confirmed that she does not administer medication. Discussion showed a staff member to understand that only the person administering medication can sign for it and therefore the previous requirement has been deleted. The Inspector saw evidence of regular support visits being provided by the supplying pharmacist with records of one visit in January 2006 showing that ‘no problems’ had been identified. There is a secured controlled drugs cupboard but this is not within a medication cabinet. The written advice of the pharmacist indicates that this is currently acceptable given the nature of the current drug held. Medications are listed in the care plan but written guidance based on the advice of the prescriber must be included in respect of criteria for the administration of medications prescribed as ‘as required’. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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): 23 Service users are generally protected from abuse, neglect and self harm but systems are not sufficiently developed to protect service users possessions. EVIDENCE: A full range of national, local and home specific policies are in place to guide staff to protect service users and to guide action in the event of a disclosure of abuse. The home’s own policy is detialed apart from one paragraph which may guide an inappropriate response in event of an incident. This section requires review. There have however been no incidents, no staff disciplinary action or dismissals and no allegationsof abuse made. The written advice of psychologists has been obtained to support staff to positively manage the behaviour of one service user. The manager demonstrates understanding of the positive functions of behaviour that can challenge and has taken action to minimise this for example. by consulting the service user and passing on her wishes to staff. Inventories of service user possessions are not in place and this does not protect service users or staff. For example, during the inspection a service user in discussion with the Inspector commented that she would like a key to her bedroom as her new clothes go missing. The Manager must investigate this and take appropriate action but an investigation is compromised by the lack of adequate recording of personal possessions. Some service users independence is being maximised by the provision of locked facilities within their bedrooms where monies can be held by the service Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 17 user for safe keeping. Receipts for large expenditures by service users are now being held, which is an improvement. Two staff sign finance records to evidence when service users receive their money but the records does not show that the recipient of the money is the service user or what the balance held by the home is once the money has been given. This make auditing of monies held on behalf of service users impossible to audit. Bank statements correlate to monies withdrawn from the bank on service users behalf by staff. Where service users are not able to hold their own money, the Social Service Department is the appointee. Money is not being collected in advance to service users from the appointee,and the proprietors use their own monies to give these service users and are the reimbursed by the appointee at a later date. While this practice avoids having to hold large sums of money on the premises on service users behalf and is administratively easier, it means that service users have no access to their own money and this could compromise service users dignity. Discussion with the Manager and staff showed that practice in respect of accepting gifts from service users is different from that advocated in the policy. The policy states that small gifts can be accepted but that they must be recorded and not to do so is gross misconduct. The Manager said that occasionally service users have bought her very small gifts, which have been accepted as per written policy but not recorded. She said however that staff know not to accept any gifts. This was verified verbally with a staff member who was clear that gifts were not to be accepted. The policy requires review. A staff member demonstrated a good understanding of what abuse is, who could abuse and her role if she became aware of or suspected abuse. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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, 30. Service users live in a homely, comfortable and generally safe environment. The home is clean and hygienic. EVIDENCE: The Inspector toured the premises which are homely, clean, uncluttered and in keeping with the local community. This inspection was unannounced during the winter period and the home was warm upon the Inspector’s arrival. None of the service users use wheelchairs within the premises. Furniture is of good quality and is domestic in style. There is not a planned written maintenance programme but the manager feels that work is done when required. She stated that ‘we just do it’. There was evidence of improvements made before Christmas when the laundry and stockroom were painted. This does not have a direct impact on outcomes for service users but is necessary to maintain the premises. Décor is generally acceptable throughout the premises. It was however noted that the dining room now requires redecoration as the lower wallpaper is ripped and chipped. The manager agreed and said improvement is imminent. CCTV cameras are in place but do not impose on the daily lives of service users. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 19 The Fire Service has inspected the home (November 2005) since the last inspection. There was no written feedback available but the manager said that the outcome of the visit concurred with the Inspector’s view that fire drills require improvement. The proprietor has sought the advice of the Infection Control nurse about the home’s Infection Control policy and minor suggestions have been made that now need to be incorporated. The home has two laundries both of which are exceptionally clean and well equipped. Systems are in place to support active infection control including the provision of staff training to all staff (except one), the provision of protective equipment, appropriate flooring, a washing machine with a sluice facility, the availability of products to appropriately absorb spillages, red dissolvable laundry bags to minimise staff handling of soiled articles. Discussion with a member of staff showed a good understanding of the principles of good infection control. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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): 32, 35 Service users are supported by competent staff almost half of whom are qualified. Staff receive appropriate ongoing training to support them to meet the needs of service users. New staff however are not receiving training to the appropriate standard early enough in their employment and are therefore not being sufficiently prepared to meet service users needs. EVIDENCE: Staff at Stoneleigh House present as interested in their jobs, motivated and committed to the welfare of service users. This was confirmed through discussion with a new member of staff who said ‘I Love it. I like the atmosphere. We all work as a team. Everyone helps. It’s a happy place’. The Manager in addition spoke positively of the staff team and their commitment to training and improving their knowledge. Staffs spoken to were aware of service users individual needs and had a grasp of knowledge of disabilities and conditions of service users in general. The manager has a good understanding of the functions of service users behaviour, which helps to minimise behaviours that challenge. Feedback questionnaires have been designed by the home to seek feedback from professionals associated with the home but opinions are not yet known. However neither complaints nor comments have been made to The Commission for Social care Inspection in respect of practice at the home. No staff are below the age of 21 or 18. One Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 21 staff member is 18 but is not left in charge of the home. Two qualified staff have left the home to take up employment elsewhere. Consequently the home is no longer meeting the target of 50 of staff qualified to NVQ level 2 by 2005. Five out of 12 staff hold the qualification which is 42 . It is reported three additional staff are however due to finish within the next few weeks. There is an effective training programme in place that is well managed with the support of a staff-training matrix. Staff have been supported to attend a range of appropriate training. Training undertaken by a night carer was case tracked by the Inspector. This staff member had undertaken training courses in 2002, 2003, 2004 and 2005. In the 12 months prior to this inspection she had done training in Care of the Dying, Dementia Care, Emergency First Aid, Fire Safety. She had previously done training in medication, diabetes, challenging behaviour, adult protection, Equal Opportunities, Moving and Handling, Food Hygiene, Health and Safety and had obtained her NVQ level 2. A training provider has been obtained to provide Induction and Foundation Training but this is not being provided to new staff in a sufficiently timely manner. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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): 39, 42 Systems are not yet sufficiently in place to assure service users that their views underpin all self monitoring, review and development by the home. The health, safety and welfare of service users are largely, promoted and protected. EVIDENCE: Quality Assurance systems to support the home to measure their own performance based upon self-assessment and third party feedback are in the process of being developed. The Inspector had sight of some newly designed templates. Relatives have been requested by the home to provide feedback and the return of questionnaires sent is awaited. Questionnaires have been designed for professional visitors feedback but have not yet been distributed. The proprietor plans to develop an action plan based upon all feedback obtained. The detailed minutes of service user meetings show meetings to be held regularly, show that service users are consulted about a range of Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 23 appropriate issues and record high levels of satisfaction. Service users must also be consulted individually and this is planned. Service records for the premises and its equipment were available and a programme of service is in place and is supported by contracts. Some services were falling due the month of this inspection but the proprietor was aware of these and many were booked. Fire systems are well serviced and checked regularly by staff. A fire risk assessment is in place to minimise the risk of fire but fire drills have not been carried out sufficiently regularly to include all staff. Fire drills said to have been carried out at staff meetings are not evidenced as the meetings themselves are not evidenced and do not give staff or service users the chance to practice under realistic conditions i.e. with usual staffing ratios. Most service users are not present during the day being at day centre. Fire training has been provided for staff twice per year. All staff have received first aid training. COSHH assessments were in place to identify risks from hazardous chemicals and such products were stored appropriately. All staff have done Food Hygiene training and fridge and freezer temperature maintenance systems are in place to minimise the risk of illness to service users as a result of none compliance with safe food storage temperatures. Radiators are guarded to reduce the risk of scalds to service users. Water outlet temperatures are being taken and recorded and those fitted with temperature regulators comply with recommended temperature ranges. Laundry and kitchen water outlet temperatures however are not controlled and whilst following Environmental Health Advice ‘hot water’ alert signs have been fitted these would not be sufficient to warn service users who have a learning disability and cannot read. Risk assessments with control measures must be put in place to measure and minimise risk of scalds from these outlets to service users. This is a previous requirement that has remained outstanding since March 2005. Water samples had been taken the day before this inspection the Inspector was informed and the results were awaited. The proprietor had also commissioned a Water Hygiene Survey In August 2005 where several priority 1 recommendations had been made. The proprietor acted upon this during the inspection day and the Inspector received a phone call on site by the contractor to confirm they had been asked to visit the following week to undertake all priority 1 remedial work required. Accident levels have reduced between 2004 and 2005. A staff member and a service user spoken to both said they feel that service users are safe at Stoneleigh House. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 x X X 1 X X 2 X Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 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 YA2 Regulation 14 Requirement Review the content of the homes pre admission assessment and include all areas as stipulated in Standard 2.3, 2.5 and 2.8. Requirement outstanding since 31.12.04 Not assessed at January 2006. The dates and detail of pre 31/01/06 admission trial visits must be recorded. At July 2005 and January 2006, No New Admission Requirement first made September 2004 Not assessed at January 2006. Care plans must include the following: Residents responsibility for housekeeping tasks Requirement first made 30.4.05 Not met at January 2006. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 26 Timescale for action 31/03/06 2. YA4 14 3. YA6 15 12(3) 28/02/06 4. YA6 15 1) Ensure that service 28/02/06 user plans cover all areas of identified need through a process of assessment and include: healthcare (routine and specialist) 2) To reproduce care plans in a format suitable for service users (not met at Jan 2006) 3) Ensure that the care plans are compiled with the service user and/or their representative and are dated/signed. Requirements not met since prior to January 2004. Not assessed at January 2006. The activity programme must be reviewed to ensure that it accords with individual service users assessed wishes and preferences. There must be increased opportunity to access the community in accordance with assessed needs. Activity outcomes for service users must be better evidenced. New Requirement at January 2006. The reason for the none provision of a holiday for service users in 2005 must be provided in writing to the Commission for Social care Inspection by 28/02/06 New Requirements at January 2006. 5 YA12 12 31/03/06 6 YA14 12 31/10/06 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 27 7 YA15 12 Care plans must be reviewed 28/02/06 with regard to regularity of family contact to ensure that this accurately meets the needs and wishes of both service users, friends and family. This must then be adhered to as per the care plan. Records of family contact / phone calls to family must be reviewed to ensure that all contact including attempted contact is recorded. New Requirement at July 2005. Not assessed at January 2006. The contract of residence between the home and service users must include the homes rules on alcohol and drugs. A bedroom key must be provided to service user MG as requested at inspection. The none- provision of keys must be reviewed with remaining service users. 8 YA16 5(b) 31/03/06 9 YA16 12 28/02/06 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 28 10 YA20 13(2) 11 YA22 22 The criteria for the administration of ‘as required’ medication must be obtained from the prescriber and included in plans of care. The complaint made by a service user to the Inspector during inspection in relation to the disappearance of clothes must be recorded, investigated with clear recorded outcomes, acted upon appropriately where necessary and communicated in writing to the Commission for Social Care Inspection New Requirement at January 2006 The homes Business account must be audited in respect of service users monies to appropriately conclude the imminent cessation of this arrangement. The findings must be forwarded to the Commission for Social Care Inspection. (Requirement originally to be met by 30.6.05) 28/02/06 27/01/06 12 YA23 25(2) 20(1)(b) 31/03/06 13 YA23 13(6) Not Met at January 2006. Inventories of service users possessions must be put in place for each service user. The policy on staff accepting gifts must be reviewed. The adult protection policy section ‘action to take’ must be reviewed to ensure the ongoing protection of service users in the event of an 31/03/06 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 29 allegation against a staff member. New Requirement at January 2006. The manager is required to ensure that when any one, of either of the two people sharing a double room, no longer occupies the room, the occupancy of that room will become single due to it being undersize, (i.e. less than 16 square metres) At July 2005 and January 2006 - No vacancy. Requirement originally made January 2004 The rota of actual hours worked must be kept up to date and accurate reflecting all changes made. Requirement originally to be met by 28.2.05 Not assessed at January 2006. The recruitment procedure must be reviewed to include an effective and safe way of involving and seeking the opinions of residents. All staff dismissals must be notified to the Commission for Social Care Inspection under regulation 37. (At July 2005 and Jan 2006No dismissals) Requirements originally made September 2004. Not assessed at January 2006. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 30 14 YA25 16,23 31/03/06 15 YA33 17(2) Sch 4 (7) 31/01/06 16. YA34 19,37 31/03/06 17 YA35 18(1)(a) New staff must complete induction training to the required standard within 6 weeks of employment. New requirement at January 2006. The regularity of supervisions of staff must increase to a minimum of six in 12 months. (At July 2005 - on target 3 in 6 months since Jan 2005requirement originally made September 2004) Supervision must include all areas as a minimum stated in Standard 36.4 (Requirement not met since 31.10. 04) (At July 2005 supervision does not include work with individual service users) Not assessed at January 2006. The manager must ensure that staff meetings are held regularly at regular intervals. New Requirement at July 2005 28/02/06 18. YA36 18(2) 31/03/06 19. YA36 18 30/06/06 20. YA39 24 Not met at January 2006 The manager must ensure that a quality assurance system is developed to ensure the inclusion of feedback from service users, independent advocates, family friends and other stakeholders. The manager must ensure that the results of the above DS0000024962.V279963.R01.S.doc 31/03/06 Stoneleigh Version 5.1 Page 31 are made available to all interested parties as per 39.4. Requirement outstanding since 30.6.05 21. YA42 13(4) Not met at January 2006. Written control measures must be put in place in respect of any unregulated water outlets (e.g. laundry and kitchen). Requirement outstanding since 4.3.05 22 YA42 23(4)(e) Not met at January 2006. The manager must ensure that by means of fire drills and practices at suitable intervals, that the persons working at the care home and so far as practicable, service users, are aware of the procedure to be followed in the event of fire. The first drill must be carried out be the date set. New requirement at January 2006. 27/01/06 04/03/05 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 YA14 Good Practice Recommendations All service users under the age of 65 must be offered the opportunity to go on a holiday in 2006 funded within the contract price and in accordance with their expressed wishes and assessment of risk. DS0000024962.V279963.R01.S.doc Version 5.1 Page 32 Stoneleigh Holiday decision-making processes must be documented. Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Stoneleigh DS0000024962.V279963.R01.S.doc Version 5.1 Page 34 - 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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