Inspection on 18/03/08 for Stoneleigh Care Home

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stoneleigh Care Home 07/11/06

Stoneleigh Care Home 11/01/06

Stoneleigh Care Home 31/01/05

Stoneleigh Care Home 06/07/04

Stoneleigh Care Home 22/03/04

Stoneleigh Care Home 16/09/03

Stoneleigh Care Home 11/12/02

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

CARE HOMES FOR OLDER PEOPLE Stoneleigh Care Home Station Road Gunness Scunthorpe North Lincolnshire DN15 8SU Lead Inspector Ms Wilma Crawford Key Unannounced Inspection 18th March 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stoneleigh Care Home DS0000002806.V349066.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoneleigh Care Home Address Station Road Gunness Scunthorpe North Lincolnshire DN15 8SU 01724 784019 01724 782585 lesleybatten@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited 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) Ms Deborah Mogg Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number disorder, excluding learning disability or of places dementia (10), Physical disability (10) Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Stoneleigh is registered as a nursing home. The service category is DE (E) Dementia over 65, MD Mental Disorder, and PD Physical Disability. The home is registered for 42 people. The home is provided in an old adapted building that was originally a private home and is owned and managed by Prime Life Ltd. The future plans for the home is to transfer it to a purpose built, single storey home in the Scunthorpe area. Work is expected to commence on this project in the next six weeks. Nursing care is provided in the home, and the home provides RMHN staff. The accommodation is provided over two floors, and there is a passenger lift to the first floor, as well as stairways. Stoneleigh is in the village of Gunness, close to Scunthorpe, there is a bus service to the town centre, but this is not regular. The home is close to the junction of the M181, and links to the M180, the M62, and the M18. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is on display in the reception area of Stoneleigh. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 7th November 2007 including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours over a period of two days. A second inspector spent a period of time with a group of residents in a lounge. The inspector was able to observe the residents experiences of living in the home and their interactions with each other and the staff. Four people living in the home, two relatives, and three staff were spoken with during the inspection. The manager was available throughout and the deputy available for part of the inspection. The main method of inspection used was called case tracking which involved selecting eight people living in the home and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at, the medication system and a sample of other documents required to be maintained by the home. An Annual Quality Assurance Assessment document was provided by the home before this visit and information from this was included as part of the inspection process of this service. Comments from replies to surveys, to people living in the home, staff relatives and professionals are also included in the report. The range of fees charged is £389.09 - £2397 (this figure includes additional funding provided for 1:1 support) per week. Items not included in the fee are toiletries, chiropody, hairdressing, newspapers and magazines, various taxis and non-emergency escorts to appointments. What the service does well: People living in the home and their relatives said that they felt that the health and personal care needs were being met. Some people were unable to say whether they felt they were being well: these people were well- dressed in clean, age appropriate clothing and attention had been paid to their hair and nail care. People being nursed in bed were being read to or had classical music playing softly in their bedrooms. Relatives spoken with said that the staff in the home was wonderful and the food offered very good. They explained that their relative always smiled at the carers and appeared happy and the care couldn’t be faulted. Any concerns could be raised with the manager or staff and this would be acted upon Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 6 promptly. Staff kept relatives up to date with their relatives care and they and the manager always made time them. People living in the home commented ‘It’s just like being at home.’ ‘The staff are very supportive and, they keep me up to date, I attend reviews and any changes to my care I am the first to be consulted.’ Other comments included, ‘They are very good and kind.’ ‘The staff are kindness itself, however, busy they are always kind and calm’ Relatives said ‘Their dignity is well maintained.’ ‘There is always plenty going on and we are welcome to join in.’ The home provides a clean and comfortable environment for the people living in the home. People spoken with liked their home and were able to bring their belongings into their bedrooms. The home is very well organised and managed, with trained staff that are well supported and have a good knowledge of residents needs. A new approach has been introduced towards nutrition in the home, as well as a wholesome, home cooked well planned menu being provided, there is also a well stocked fridge with a glass door, stocked with fresh fruit, yoghurts, crisps, cakes, sandwiches. This offers a visual stimulus to people living in the home and the opportunity to enjoy a variety of snacks in between planned meal times. The meals provided were varied and well cooked and presented. One person said, ‘the meals are very good with good variety’, and another ‘you can’t fault it, there’s lots of choice and it’s well cooked’. People living in the home have the opportunity to participate in a wellorganised activity programme, provided by a designated activities coordinator. What has improved since the last inspection? What they could do better: Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 7 On the first day of the site visit there was an odour detected in the entrance of the building, when this was raised with the manager, the two domestic staff had called in sick. A further two members of the care staff team were attending training; the home had been unable to cover the shortfalls on the rota. The home needs to consider how staffing levels can be maintained to ensure that staffing levels are maintained to meet the needs of the people living in the home at all times. On a tour of the building, covers to the pipe work in the bathrooms had been removed and not replaced, which could potentially present a risk to people living in the home. The external windows were in poor condition with beading missing and in need of repainting. The paint finish on one of the bath hoist chairs showed signs of starting to rust and flake and needs to be repaired/ replaced. One of the eight care plans examined had not been evaluated in the last two months. All the others seen were complete and current. Staff spoken to said that they would benefit from training that would offer them guidance in how they could communicate more effectively with the people living in the home with more profound disabilities, as some staff had difficulty with this. The portable appliance equipment in the home has not been tested since December 2005; this should be completed on an annual basis. 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 Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 People who use this service experience good quality outcomes in this area. People are provided with information and their individual needs are assessed before admission to ensure they can be met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence seen at this inspection in service users files and care plans showed that the home does not admit people without a care assessment being undertaken. Prospective service users are assessed very carefully due to the layout of the building and the vulnerability of the people living there. People are written to by the home confirming that they can meet their care needs or not. Each individual has a statement of terms and conditions, which are signed by them or their representative. They are also encouraged to visit the home before they make a decision as to whether they wish to live there. Discussion with people living in the home and relatives also confirmed that this happened. Comments about the home included; ‘I have never had any grumbles about the staff or the care,’ ‘The staff are very good to my husband. I can’t speak Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 10 highly enough about the staff.’ ‘We are involved in all aspects of our relatives care and we are very happy with the care provided.’ Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good quality outcomes in this area. People receive a good standard of care and health and personal care needs are routinely met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen showed that they are developed from the initial needs assessment carried out by the home. Reviews of the plans are monthly to ensure that they are still current and any new issues have been addressed. One of the eight care plans seen had not been evaluated for the last two months. Risk assessments are available, including a falls risk assessment. Any pattern or frequency of falls are quickly identified and referred to falls specialist liaison worker. Care plans and risk assessments are quickly updated to reflect the changing needs of the individual and how these should be met. There was evidence that all residents have access to relevant health care professionals. Care plans also evidence that health care professionals visit the home, including consultants, when people are unable to visit the hospital or local surgeries for appointments. There was also evidence to demonstrate that advice is sought from the tissue viability nurse and the continence advisor. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 12 A visitor commented that they are happy with the care provided and confirmed that their relatives see the GP, district nurses, and the chiropodist as they would were they living in their own home. People living in the home said that they were consulted about their care and were aware of their care plans. Professionals commented that the staff were approachable and were receptive when new or different ideas were suggested to them. Individuals’ files also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. The home’s accident book was examined and it was found that accidents occurring to residents have been recorded appropriately in their individual file and appropriate remedial action to prevent further problems arising. This information had also been made available to the Commission by the home. The home uses an approved Monitored Dosage System for the administration of drugs. Medication records showed that all drugs administered were recorded on the resident’s individual records sheet. There were no gaps in recording seen. Ten people are currently in receipt of controlled medicines, these were appropriately stored and records maintained for these corresponded to the stocks stored within the home. The nurses have responsibility for the administration of all medicines in the home. Medication audits are undertaken on a regular basis, both in house and by an independent pharmacist The inspector also checked with people living in the home to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed that the majority of the whole staff offered support at each individual’s pace, with empathy and understanding. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good quality outcomes in this area. People are offered a range of activities and relatives and friends are encouraged to be involved in the service. Food and drink provided are of a good standard. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that the food at this home is varied and well prepared. Menus were inspected and found to offer choices for all mealtimes. Menus are available on the dining tables and on display on the notice board. The chef and care staff were observed asking each person what they would like from the menu. The menu is planned in consultation with people living in the home (where possible) and there is always a minimum of two hot choices at mealtimes and special diets are catered for. A new approach has been introduced towards nutrition in the home, as well as a wholesome, home cooked well planned menu being provided, there is also a well stocked fridge with a glass door, stocked with fresh fruit, yoghurts, crisps, cakes, sandwiches. This offers a visual stimulus to people living in the home and the opportunity to enjoy a variety of snacks in between planned meal times. Staff and relatives commented that people living in the home have taken more interest in their food since this has been introduced. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 14 The homes pre-assessment forms were seen and included individuals’ dietary needs and listed their likes and dislikes. Staff spoken with, were aware of individuals personal likes and dislikes. Residents are able to take their meals in the dining rooms or as a tray service in the lounges or their rooms. Observations made by the inspector were that the staff available on the day were busy during mealtimes with little time to spend with each individual, but supported them in a patient and dignified manner. Four service users seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. Visitors are also welcome to take meals with their relatives and this practice was observed during the visit to the home. A resident confirmed that she could take her visitors to her bedroom. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. Residents and relatives meetings are held in the home and the outcome of these is used within the homes Quality Assurance Reviews. People living in the home and relatives are also consulted through the homes Quality Assurance process. Results from surveys and any relevant action plans are displayed on the homes notice board. One person said ‘I’m involved in all aspects of my care and the day to day running of the home.’ The home undertakes a variety of activities for the stimulation of residents and a record of these is maintained. During the morning of the inspection a hairdresser was visiting the home. In the afternoon various tabletop games were being held, old films were being played in the lounge and preparations were underway for Easter. There is a varied activity programme available within the home and an activity coordinator available to support staff to facilitate this. However, observations of this demonstrated that the most able people living in the home are better provided for. Discussion with staff showed that they are not always able to communicate effectively with the more disabled individuals. People living in the home would benefit from staff being provided with additional training to improve their understanding of and improve their communication skills with this group of people. The activity programme has been developed by asking people what they would like to do. Recent activities held includes; quizzes, a Valentines party, coffee afternoons, trips to the circus, Cleethorpes, Lincolnshire Life Museum and Rand farm. Day trips are available three times a month; this will be increased to four times in April. Relatives are also encouraged to participate in activities within the home and day trips. People confirmed that a planned activities programme is in place within the home, but that they also have the opportunity to go out into the town and local community, on day trips, attend church and coffee mornings. A number of fundraising events are also held in the home the proceeds of which are used for further activities. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 People who use this service experience good quality outcomes in this area. Complaints are listened to and acted upon, and people feel safe and protected. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The home takes all complaints seriously. The AQAA states that there have been no complaints made directly to the home in the last year. One complaint was made directly to the Commission for Social Care and Inspection; this was investigated by the proprietor and appropriately resolved within the agreed timescale. There has also been a safeguarding referral made, this was investigated and the outcome considered that the home did not fully adhere to the advice given to support an individual within the home. A copy of the home’s complaint procedure is displayed in the home. Service users and their relatives are made aware of the complaints procedure on admission and this was confirmed during discussion. Staff members were aware of the procedure and the documentation used to record complaints. Two people using the service spoken with confirmed that they felt safe in the home. One stated, ‘I have never had any cause to make a complaint, but if I did I’m sure that the staff would take action. They would definitely sort it out.’ They also said that they would feel confident about approaching staff with a complaint. There is a whistle blowing policy in place and a clear adult abuse policy. The home has a copy of local authority guidelines for reference and staff received Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 16 spoke knowledgeably about abusive practices and what action they would take if this came to their attention. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26 People who use this service experience adequate quality outcomes in this area. The environment for people living in the home was generally good, however further improvements to the facilities were needed to ensure that it was safe. The judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been a continuing programme of refurbishment and redecoration within the home, providing people with a clean and comfortable environment. There is a selection of lounges, sitting and dining areas for people to use and a safe garden with accessible seating areas. The home is equipped with handrails; grab rails and adapted equipment to promote service users independence. There is a lift to the second floor of the home and a call system. Each call bell is situated within easy reach for service user’s use. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 18 Rooms were individual and personalised with photographs and other memorabilia and people had the opportunity to bring some of their own furnishings into the home if they wished. Each bedroom had lockable facilities and privacy locks to the doors. People living in the home were happy with their rooms and relatives commented that rooms were always fresh and clean. The laundry was well organised and equipped with industrial type washing machines and driers. A laundry assistant is available for 42 hours each week. Relatives and people living in the home commented on the standard of laundry service provided was quite good, but there were occasions where delicate clothing had been damaged, by washing instructions not being followed. This had been resolved with the manager. Overall the home was clean and odour free, however on the first day an odour was identified in the entrance hall. The two domestic staff had called in sick on this day. During a tour of the building several maintenance issues were identified. A carpet on the landing was starting to fray and had the potential to create a trip hazard. Pipe work in the bathrooms had been uncovered and the covers not replaced, which could present a further hazard. The external windows had beading missing and were in need of repainting, to prevent the wood becoming damp. The arm positioning a hoist over a bath was showing signs of beginning to rust, which had the potential to present a hazard to the people using it. Clinical waste bins were also seen to be rusty and in need of replacement. Information included in the AQAA showed that electrical equipment within the home had not been checked since 2005, this should be completed on an annual basis. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 People who use this service experience good quality outcomes in this area. People using the service have their needs met by a competent and trained staff group, who are recruited appropriately. The judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff are subject to an induction and statutory training, which includes, Fire Safety, Food Handling, COSHH, Manual Handling, Health and Safety, Dementia and First Aid. Nurses are supported to maintain the professional development and in maintaining their nursing skills. This includes wound management, Safe handling of Medicines, Dementia, Catheter Care, the Registered Managers award, Diabetes management and Non Physical Interventions. The organisation has a training manager whose role includes ensuring that staff have the necessary skills and knowledge for their roles. Staff confirmed during discussion that any training identified as a need would be provided. 43 of the care staff team have a National Vocational Qualification (NVQ) at level 2 or above and a further 19 are working towards this qualification. Training is provided through a mix of in-house, external facilitators, distance learning, local colleges and visiting professionals. The home records all training undertaken by care staff. Regular staff meetings are held and staff receive supervision and appraisals, which are recorded. Staff spoken with said that they felt well supported in their roles. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 20 Examination of the staff files showed that supervision had taken place but records suggested that this had only been over the last three months. Discussion with staff and the manager confirmed that regular supervision takes place within the home and there is now a structured plan in place to continue with this. Appropriate checks for all new workers are completed before they commence work at this home. Two new staff files were examined and both had application forms, two references, POVA first checks, and clear Criminal Record Bureau Checks prior to the start of their employment. The duty rota showed that two nurses, the manager, six care staff, a cook and kitchen assistant, a laundry person and two cleaning staff were available to meet the needs of thirty eight people during the day. In the afternoon there is one nurse on duty from 2pm, six care staff and an activities coordinator. One nurse and three carers are available throughout the night. Additional staffing is provided on a 1:1 basis as identified within individuals’ contracts. Staff said that they felt stretched at the busiest times of the day and that they would benefit from additional staffing. The inspector observed that there were times where people had to wait a short time for support due to the high level of the needs of the people living in the home. On the day of the visit this was impacted further by the fact that two staff members had rung in sick and a further two were training, leaving the home with fewer staff than had been allocated on the staffing rota. The staffing levels should be reviewed regularly and altered to accommodate the needs of the people living in the home at any one time. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38 People who use this service experience good quality outcomes in this area. People using the service benefit overall from a safe and well managed home. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has been registered with the Commission for Social Care Inspection and has worked in the home during the 8 months. She is competent through her experience and has extensive experience of working with people with Mental Health issues. She has the Registered Managers Award and an NVQ level. Staff said they are well supported and they are confident to approach the manager with concerns or ideas. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 22 Staff, relatives and people living in the home commented; ‘The Manager is excellent, she is always there and available to talk’. The minutes from the recent residents’ meeting show that residents contribute and raise issues, and that action is taken to address these. The home has a quality assurance system in place that is based on seeking information from the manager, staff, residents, relatives and other visitors to the home. It is obtained through discussion, interviews and comment cards, depending on the individual needs of the person. A detailed report is completed from the information collated and areas, in which the home excels or identified areas that need to be improved, are included. Staff are now being supervised regularly both formally and during every day observation. Annual appraisals also take place. Assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are also kept. Records within the home are stored securely and service users said they were aware that they can see them if they wish. Policies and procedures were found to correspond to the information made available by the home in the Annual Quality Assurance Assessment document. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training. Certificates were available showing that the shaft lift and bath hoists had been serviced six monthly. Wheelchairs seen on the day of the inspection had footplates, which were in use. Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 2 X 2 2 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 2 Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 23(2)b Requirement The provider must ensure that the beading to the external windows is repaired, missing beading is replaced and repainted to maintain safety within the home. The provider must ensure that the worn carpet on the landing outside of room 43 should be repaired or replaced to prevent a trip hazard from developing. The provider must ensure that the arm to the bath chair in the downstairs toilet is replaced or repaired. The provider must ensure that all portable appliances within the home are routinely checked on n annual basis. Timescale for action 30/04/08 2. OP19 13(4)a 30/04/08 3. OP22 23(2)c 30/04/08 4. OP38 23 (2)c 30/04/08 Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP12 Good Practice Recommendations The manager should ensure that all care plans are evaluated on a monthly basis. The manager should look at what training could be provided to the staff team to develop their understanding and communication skills with the more disabled people living in the home. The manager should ensure that the home provides a staff team, in sufficient numbers to support service users assessed needs at all times, and that satisfactory arrangements are in place to provide the necessary cover in times of absence of staff for example sickness or training. The manager should ensure that all care staff receive. formal supervision at least six times a year. 3. OP27 4. OP36 Stoneleigh Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Care Home DS0000002806.V349066.R01.S.doc Version 5.2 Page 27 - 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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