Inspection on 21/05/07 for Stoneleigh

This inspection was carried out on 21st May 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stoneleigh 20/01/06

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 Lesley Webb Key Unannounced Inspection 21st May 2007 09:45 Stoneleigh DS0000024962.V330187.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 Stoneleigh DS0000024962.V330187.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. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 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.V330187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 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.V330187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this inspection over one day with the home being given no prior notice. During the visit time was spent talking to staff and people who live at the home, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen consisted of both male and female and have different communication and care needs. No relatives of residents were present during the inspection however four relatives questionnaires were completed and sent to the Commission for Social Care Inspection prior to the visit. Information from these, and from resident’s questionnaires, was also used when forming judgements on the quality of service provided by the home. Fees charged for living at the home range from £408 to £743 per week with additional charges for hairdressing and toiletries. The atmosphere throughout the visit was relaxed and welcoming and the inspector would like to thank residents and staff for their co-operation and assistance. What the service does well: There are currently seventeen people residing at the home, all of who completed questionnaires supplied by the Commission for Social Care Inspection (CSCI) with assistance from staff prior to this visit. All confirm that they received enough information about the home before they moved in so that they could decide if it was the right place for them. In addition to this four relatives also completed questionnaires. All four state that the care home always meets the needs of their relative. Additional comments include, ‘The home is a excellent place, very caring staff’. Regular residents meetings take place in order to support people in decisionmaking processes. As one member of staff explained, “we do monthly meetings so they can say what they want to do, if they express certain wishes we help them to achieve these and meet their goals”. Evidence suggests people living at this home participate in social and recreational activities based on their individual needs and capabilities. For example people were seen sitting writing, watching television, completing puzzles and a resident also informed the inspector that the home had arranged a birthday party for her at a local pub which she really enjoyed. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 6 The home welcomes visitors and supports people to maintain contact with relatives and friends. As one relative stated on a questionnaire completed and returned to CSCI, ‘if my relative wants to telephone any of us the staff are always at hand to help her do that’. The health and personal care that people receive is based on their individual needs. Of the four relatives questionnaires completed and returned to CSCI prior to the inspection all state that the care service meets the different needs of people, with an additional comment made by one relative, ‘they treat each resident individually whatever their disability’. A General Practitioner completed a survey form and returned it to CSCI praising the home stating, ‘the home always offer good support for residents when health care requested, good communication with surgery, good compliance and follow up at recognition of illness, staff appear to understand all issues’. All staff that were spoken to demonstrated good understanding of supporting people to raise concerns. For example one person explained, “We talk about concerns in residents meetings, ask if anyone has any complaints and also ask individually and give opportunities to talk away from the group. If I know someone looks upset I will ask if ok and discuss to try to sort any problems or issues”. The Inspector toured the premises which are homely, clean, uncluttered and in keeping with the local community. Two relatives gave additional praise to the home in questionnaires sent to CSCI stating, ‘Its always clean and tidy’ and ‘The home is always clean and welcoming no matter what time you go’. Good quality assurance systems are in place that allow the home to measure if it is meeting its aims and objectives. For example the views of residents have been obtained within residents meetings and questionnaires and these have been analysed and included in the annual development plan for January to December 2007. What has improved since the last inspection? All but one of the requirements identified in the previous inspection relating to care plans is now met. The registered manager confirmed that care plans now include resident’s responsibilities for housekeeping tasks, healthcare needs are identified and that plans are complied with individuals and/or their representatives. Activity programmes have also been reviewed to ensure that they accord with individual service users assessed wishes and preferences and opportunities to access the community in accordance with assessed needs have also improved. Records of family contact / phone calls to families now evidence that support is given in this area as per each residents wishes. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 7 The criteria for the administration of ‘as required’ medication has been obtained from the prescriber and included in plans of care ensuring greater protection to people living at the home. The homes policies on staff accepting gifts and adult protection have both been reviewed to ensure the ongoing protection of residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stoneleigh DS0000024962.V330187.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 Stoneleigh DS0000024962.V330187.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people considering this home have information and their needs assessed in order that they and the home can be confident that needs can be met. EVIDENCE: There have been no new admissions to the home for several years however the proprietor states that admissions documentation has been reviewed and expanded to include all the required information as detailed in the National Minimum Standards for Younger Adults. The documentation was viewed by the inspector and appears appropriate. There are currently seventeen people residing at the home, all of who completed questionnaires supplied by the Commission for Social Care Inspection (CSCI) with assistance from staff prior to this visit. All confirm that they received enough information about the home before they moved in so that they could decide if it was the right place for them. In addition to this four relatives also completed questionnaires. All four state that the care home always meets the needs of their relative. Additional comments include, ‘The home is a excellent place, very caring staff’. Stoneleigh DS0000024962.V330187.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. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: All but one of the requirements identified in the previous inspection relating to care plans is now met. The registered manager confirmed that care plans now include resident’s responsibilities for housekeeping tasks, healthcare needs are identified and that plans are complied with individuals and/or their representatives. Sampling of three peoples plans confirmed this information to be correct. Plans are still required to be reproduced in formats suitable for people living at the home in order to promote their involvement in care planning processes. The registered manager explained that she has attended training for person centred planning and obtained guidance relating to this. She is aiming to start introducing this form of planning within eight to ten Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 11 weeks. It is recommended that staff undertake training in the values and principles of this form of support in order that they have understanding suitable for ensuring its implementation as only one member of staff that was spoken to was able to demonstrate knowledge in this area. As at the previous inspection all plans sampled contained preferences, restrictions, risk assessments, behaviour guidelines, up to date medication and good communication guidelines for working with service users who are less able to verbally communicate. For those people who have specific communication guidelines developed by speech and language therapists it is recommended that these be incorporated into the homes communication plans for ease of reference and to ensure all staff are aware and knowledgeable of their contents. All staff that the inspector spoke to demonstrated knowledge of the communication needs of people with limited speech however some were not able to give examples of the contents of a particular persons communication guidelines. Behaviour guidelines are based upon the preferences and abilities of individuals. Of the four relatives questionnaires completed and returned to CSCI all state they are always kept up to date with important issues affecting their relative. Additional comments include, ‘I am always informed of hospital visits as I like to go with her’. When examining the daily records completed by staff the inspector found that night staff records detail hourly checks throughout the night for the majority of people residing at the home. This practice was discussed with the registered manager as care plans and risk assessments do not demonstrate why this is required and the inspector was concerned with the potential intrusion to residents. As in previous inspections the home is performing well with respect to respecting residents rights to make decisions. Of the seventeen questionnaires completed by people living at the home fourteen state they always make decisions about what they do each day and three sometimes. All seventeen questionnaire state they can do what they want during the day, evening and at the weekend. The proprietor explained that everyone living at the home is offered a key to their bedroom and for those who decline or are not able to communicate their wishes in this area keys are stored in their bedroom in order to promote individuals rights to choose to use or not. Regular residents meetings take place in order to support people in decisionmaking processes. As one member of staff explained, “we do monthly meetings so they can say what they want to do, if they express certain wishes we help them to achieve these and meet their goals”. Risk assessments are in place for individuals residing at the home that identify areas of risk and control measures to reduce these. Assessments include those for mobility, medication, the environment and equipment. The age range of people living at the home varies from 49 to 93. Particular consideration has been given in relation to age with assessments in place for falls, tissue viability, weight and nutrition. Stoneleigh DS0000024962.V330187.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): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home are able to make choices about their life style, and supported to develop their life skills. Social, educational and recreational activities meet individual’s expectations. EVIDENCE: Evidence suggests people living at this home participate in social and recreational activities based on their individual needs and capabilities. People attend traditional day centre settings either full or part time. Information supplied by the home prior to the inspection states that activities arranged by the home include reading, listening to music, writing, bingo, exercise classes, card games, board games, drawing, colouring, making cards and stencilling. External activities include attendance at day centres, shopping, walks, visits to the zoo, public house, cinema, museum, theatre, sea life centre and the seaside. Sampling of records and observations during the inspection confirm Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 13 this information to be accurate. For example people were seen sitting writing, watching television, completing puzzles and a resident also informed the inspector that they home had arranged a birthday party for her at a local pub which she really enjoyed. Since the last inspection activity programmes have been reviewed to ensure they meet individuals wishes and preferences and opportunities have increased to access the community. Activity records now include not only events that people have participated in but also those that they have been offered but declined. People who live at this home do not go on an annual holiday; with records evidencing this is regularly discussed in residents meetings, with people choosing to participate in day trips instead. The home welcomes visitors and supports people to maintain contact with relatives and friends. As one relative stated on a questionnaire completed and returned to CSCI, ‘if my relative wants to telephone any of us the staff are always at hand to help her do that’. All four relatives questionnaires state that the home always keeps them up to date with important issues affecting their relative. All residents’ files sampled during the inspection contained good records of family contact including visits and telephone calls. People living at the home were discreetly observed from another room participating in a meal. Staff were seen to offer assistance in a discreet and respectful manor. The atmosphere was relaxed and friendly. As at previous inspections a rolling menu is in place with records kept to account for deviations from the menu including deviations as a result of resident’s choice and requests. Systems are in place to identify and respond to residents at nutritional risk and outcomes for these individuals are good with one person who is at particular nutritional risk having been supported to appropriately gain weight. Stoneleigh DS0000024962.V330187.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. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: As at previous inspections evidence indicates that the health and personal care that people receive is based on their individual needs. Care plans provide good detail to guide staff in the appropriate provision of personal care to individuals. The written guidance considers the abilities and preferences of each person. Of the four relatives questionnaires completed and returned to CSCI prior to the inspection all state that the care service meets the different needs of people, with an additional comment made by one relative, ‘they treat each resident individually whatever their disability’. Health records are detailed and evidence that the needs of people are being met with regular appointments with a range of specialists being kept. Routine health screening is also being provided for example chiropody and optical Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 15 services. Nutritional screening and residents weights are regularly taken and reviewed. The services of a dietician have been secured and advice implemented. A General Practitioner completed a survey form and returned it to CSCI praising the home stating, ‘the home always offer good support for residents when health care requested, good communication with surgery, good compliance and follow up at recognition of illness, staff appear to understand all issues’. Medication systems in place generally support good practice. Information supplied by the home prior to the inspection states that seven staff are responsible for administering medication, that nine staff are currently undertaking distance learning medication management and that thirteen staff have completed ‘Boots Monitored Dosage System training’. It is recommended that the home obtain CSCI guidance ‘medication training for staff in residential homes’ and implement suggested competency assessments to ensure staff’s practices reflects the knowledge gained through training. During the inspection the registered manager confirmed that the criteria for the administration of ‘as required’ medication has been obtained from the prescriber and included in plans of care, meeting a previous requirement. Records for medication entering, being administered and leaving the home appear appropriate. The storage of medication also appears appropriate, however it is recommended that the fridge used to store medication have a lock fitted to it to offer greater protection; as this is located in a secondary kitchen used by residents when baking. It is also recommended that the home review its stock of medication again to offer greater protection to people living at the home, as amounts appear excessive in some areas. Stoneleigh DS0000024962.V330187.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 good. This judgement has been made using available evidence including a visit to this service. People who live at this home are supported to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: The home has good systems for supporting people to raise concerns or complaints. For example a there is a comments log available in the entrance hall and the complaints policy and form has been sent to all relatives. Complaints literature is in a user-friendly format and posted throughout the home. The Complaints policy undertakes to manage complaints within 28 days and the use of advocates in expressing complaints is acknowledged within the homes policy too. The policy makes it clear that residents and their families will not be victimised for making a complaint. All questionnaires completed by residents and relatives confirm they know how to make a complaint and who to speak to if not happy. One relative questionnaire also states, ‘I have never had cause to raise any concerns. I have always found the staff and management very approachable with any matters relating to my sister’. All staff that were spoken to demonstrated good understanding of supporting people to raise concerns. For example one person explained, “We talk about concerns in residents meetings, ask if anyone has any complaints and also ask individually and give opportunities to talk away from the group. If I know someone looks upset I will ask if ok and discuss to try to sort any Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 17 problems or issues”. As at previous inspections a full range of national, local and home specific policies are in place to guide staff to protect people living at the home and to guide action in the event of a disclosure of abuse. Information supplied by the home prior to the inspection states that Dudley Metropolitan Borough Council handles the financial affairs for everyone living at the home. A training matrix supplied details thirteen staff employed, ten who have undertaken challenging behaviours training, eleven adult protection and nine complaints procedure training. A previous requirement to ensure inventories of residents possessions must be put in place is part met. All files sampled during the inspection contained inventories of clothing and jewellery, however none detailed personal affects such as videos, ornaments and other items purchased from their own monies or given as gifts. All other requirements relating to protection identified in the previous inspection are now met. For example the homes business account is no longer used for banking residents monies, the policy on staff accepting gifts and the adult protection policy have been reviewed and improved, offering greater protection to residents. When examining the homes protection policies the inspector found that the restraint policy states ‘no member of staff will use physical restraint of any kind on a service user’. The policy also states because restraint is not used the home will not provide training in this area. The same policy then goes on to state ‘only as last resort should you attempt to use physical restraint in order to protect yourself’. This was discussed with the registered manager who was instructed to review this policy as it appears to contain contradicting information that if used has the potential to place residents at risk if restraint is used by untrained staff. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and generally safe environment. The home is clean and hygienic with infection control practices protecting people. EVIDENCE: The Inspector toured the premises which are homely, clean, uncluttered and in keeping with the local community. Furniture is of good quality and is domestic in style. Décor is acceptable throughout the premises. Information supplied by the home prior to the inspection states that the downstairs bathroom, dining room, conservatory and smoking area have been decorated since the last inspection and that the exterior of the home has also received attention. CCTV cameras are in place but do not impose on the daily lives of residents. Two relatives gave additional praise to the home in questionnaires sent to CSCI stating, ‘Its always clean and tidy’ and ‘The home is always clean and welcoming no matter what time you go’. The home consists of two Victorian Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 19 buildings that have been converted into one home. Bedrooms are located on three floors and there is not passenger lift. There is a chair lift located on one of the stairways. As mentioned earlier in this report the age range of people living at the home varies from 49 to 93. The inspector found no evidence that the home is not meeting the physical needs of people residing there. Handrails are in place along with other adaptations including commodes and shower chairs. When examining equipment some of the commodes were found to be rusty and a shower chair damaged, both of which pose risks to residents. It was therefore pleasing to note that when these issues were reported to the proprietor action was taken immediately to address these. The home has two laundries both of which are clean and well equipped. Systems are in place to support active infection control including the provision of staff training to staff, the provision of protective equipment, appropriate flooring, a washing machine with a sluice facility, the availability of products to appropriately absorb spillages and red dissolvable laundry bags to minimise staff handling of soiled articles. When assessing infection control procedures the inspector noted that there is currently not system for the storage and sanitizing of mop heads. This was discussed with the registered manager and proprietor who made arrangements to rectify this immediately. The home has a copy of infection control guidance issued by the Department of Heath however this is not the most current edition. It is recommended that the updated version be obtained in order that the home can monitor that information and systems are based on current good practice. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally staff in the home are trained, skilled and in sufficient numbers to support the people who live there. Improvements to some recruitments practices will offer greater protection to people living there. EVIDENCE: As in previous inspections staff at Stoneleigh House present as interested in their jobs, motivated and committed to the welfare of the people living there. Staffs spoken to were aware of resident’s individual needs and had a grasp of knowledge of disabilities and conditions of individuals in general. All seventeen questionnaires completed by people living at the home states that staff always treat them well and listen and act on what they say. The recruitment records of four members of staff were sampled to assess if the homes recruitment procedures ensure people living at the home are safeguarded from harm. A previous requirement to introduce systems for seeking the opinions of residents when recruiting new staff is now met. A Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 21 form has been introduced where the views of residents are recorded when candidates visit the home as part of the recruitment process. Views are then used when deciding on a person’s suitability. All staff files sampled contained evidence that the required CRB disclosures having been obtained prior to staff commencing employment along with other documentation including application forms, contracts of employment and proof of identification. None of the four files sampled contained evidence that references have been obtained as part of the recruitment procedure. The proprietor produced documentation verifying that two of the staff members had been employed at the home for several years and were already in position when he purchased the home. The registered manager confirmed that the remaining two members of staff had been employed without obtaining references. An immediate requirement form was issued instructing the home to cease the practice of employing staff without obtaining all required documentation as detailed in the Care Home Regulations 2001 in order to safeguard people living at the home from risk of harm or abuse. During the inspection the proprietor produced evidence that he had taken action to address the issue of outstanding references. There is an effective training programme in place that is well managed with the support of a staff-training matrix. Information supplied by the home prior to the inspection states that of the thirteen staff employed eleven hold certificate for diabetes, equal opportunities, dementia care and care of the dying, nine privacy and dignity of residents, aims and objectives of Stoneleigh, accident procedures and missing residents procedure, seven National Vocational Qualification (NVQ) level 2 and six learning disability award foundation (LDAF) induction. All staff files sampled contained evidence that they receive regular, formal supervision. In addition to this regular staff meetings are held. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect and effective quality assurance systems ensure the home can measure if it is meetings its aims and objectives. EVIDENCE: The registered manager has more than 2 years significant management experience in a care setting and is qualified and competent to run the home. A deputy and the proprietor, all of who have designated areas of responsibility, support the registered manager. Good quality assurance systems are in place that allow the home to measure if it is meeting its aims and objectives. The homes quality management policy Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 23 states people living at the home can ‘expect the highest care and accommodation possible, will be given a say in running of the home through regular monthly meetings and surveys’. This statement was found to be accurately reflected in the quality assurance records maintained within the home. For example the views of residents have been obtained within residents meetings and questionnaires and these have been analysed and included in the annual development plan for January to December 2007. In addition to this the views of staff and relatives have also been obtained and analysed. It was also pleasing to find that the home has maintained the ‘Investors in People’ status. Information supplied by the home prior to the inspection states that a fire officer visited the home on 14/11/05, fire equipment was checked 21/02/07, the most recent fire drill took place 29/03/07, fire alarms are tested weekly, health and safety consultants visited on 19/01/06 with all actions completed, a environmental health officer visited 14/09/06 with no action required, a landlords gas certificate was issued 19/01/07, Leionella checks are completed weekly, an electrical wiring certificate was issued 19/05/06 and the emergency lighting was checked 31/03/07. A random sampling of records during the inspection found this information to be accurate ensuring the management of health and safety safeguards people living at the home. In addition to this of the thirteen staff employed at the home eleven hold up to date certificates for first aid, food hygiene, moving and handling, fire, health and safety and infection control. A previous requirement to introduce written control measures in respect of any unregulated water outlets is now met. Work must now be undertaken to ensure that records are maintained in sufficient detail that evidence regular fire drills occur, involving all staff and where practicable people living at the home. Improvements in this area will reduce the risk of injury to everyone in the event of a fire. Safe working risk assessments were seen for new and expectant mothers, security, medication and other areas relating to health and safety. No risk assessments are currently in place for staff that work above 48 hours per week. It is recommended that these be introduced to ensure management monitor that people living at the home are supported by staff that are fit for purpose. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 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 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 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 01/08/07 2 YA23 13(6) 3 YA23 13(6) 4 YA34 19(1)(b)(c) That care plans and risk assessments demonstrate the need for hourly checks throughout the night of residents (as is the current practice) in order that resident’s rights to privacy are not compromised. Inventories of service users 01/08/07 possessions must be put in place for each service user in order that records protect individuals– part met. This requirement was originally made January 2006. To review the restraint policy 01/08/07 as it appears to contain contradictory information that if used has the potential to place residents at risk if restraint is used by untrained staff. To cease the practice of 21/05/07 employing staff without obtaining all required documentation as detailed in the Care Home Regulations 2001 in order to safeguard people living at the home from risk of harm or abuse. DS0000024962.V330187.R01.S.doc Version 5.2 Stoneleigh Page 26 5 YA42 23(4)(e) There must be fire drills and 01/07/07 practices at suitable intervals so 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 to reduce the risk of injury to people. This requirement was originally made January 2006. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA6 YA6 Good Practice Recommendations That care plans be reproduced in formats suitable for people living at the home in order to promote their involvement in care planning processes That staff undertake training in the values and principles of person centred planning in order that they have understanding suitable for ensuring its implementation For those people who have specific communication guidelines developed by speech and language therapists it is recommended that these be incorporated into the homes communication plans for ease of reference and to ensure all staff are aware and knowledgeable of their contents. That the home obtain CSCI guidance ‘medication training for staff in residential homes’ and implement suggested competency assessments to ensure staff’s practices reflects the knowledge gained through training. That the fridge used to store medication has a lock fitted to it to offer greater protection. That the home reviews its stock of medication to offer greater protection to people living at the home. That the home obtain the updated version of infection control guidance issued by the Department of Heath in order that the home can monitor that information and systems are based on current good practice. That risk assessments be introduced for staff that work in excess of 48 hours a week to ensure management monitor that people living at the home are supported by staff that DS0000024962.V330187.R01.S.doc Version 5.2 Page 27 4 YA20 5 6 7 YA20 YA20 YA30 8 YA42 Stoneleigh are fit for purpose. Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 28 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: 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 Stoneleigh DS0000024962.V330187.R01.S.doc Version 5.2 Page 29 - 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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