Inspection on 07/11/06 for Stoneleigh Care Home

This inspection was carried out on 7th November 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stoneleigh Care Home 18/03/08

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 Eileen Engelmann Key Unannounced Inspection 7th November 2006 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.V319236.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.V319236.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) Mrs Lesley Batten 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.V319236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 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 service users. Stoneleigh is an old adapted building that was originally a private home. The home is owned and managed by Prime Life Ltd. The future plans for the home is to transfer the home and its services to a purpose built, single storey home in the Scunthorpe area. Land continues to be sought for this purpose. 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 MI80, 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. Information given by the manager on 04/10/06 within the Pre-Inspection Questionnaire indicates the home charges fees from £327.00 and nursing care clients also pay their nursing band determination on top of the basic fee. Residents will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these can be obtained from the manager. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The registered manager was away on leave when the inspector called in, so the unannounced visit was carried out with assistance from the deputy manager of the home, staff, relatives and residents of Saltshouse Haven. The visit took place over 1 day and included a tour of the premises, examination of staff and resident files and records relating to the service. Four staff members, one visitor and three of the residents were spoken to; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to a selection of relatives, residents and staff and their written response to these was poor. The inspector received 3 back from relatives (20 ), 5 from staff (33 ) and two from residents (13 ). The provider completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. What the service does well: What has improved since the last inspection? Medication recording has improved to ensure all signatures are in place for medications received by the staff, so that there is no mishandling of medication and the residents health is looked after. The above area of practice was a requirement in the last inspection report, and now meets the standards. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 6 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 Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. Quality in this outcome area is good. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents at the home have their own personal file and the four looked at included one for a new resident. Each individual had a need assessment completed by the funding authority and the home has also completed its own needs assessment before a placement was offered to the resident. The home develops a comprehensive care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the resident and family. The file for the new resident was incomplete, but staff are in the process of accumulating more information as they get to know the individual and are putting this into the resident’s care plan. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 9 Those residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the Health Authority, to determine the level of nursing input required by each individual. Information from the Pre-Inspection Questionnaire completed by the manager and discussion with the residents and staff, indicates that the majority of residents are White/British and those from other countries have adopted British culture and ethnicity. Discussion with the residents and checks of the care plans indicated that their diverse needs regarding communication, diets and religion are being met. Staff members on duty were knowledgeable about the needs of each resident and had a good understanding of their specific problems/abilities and the care to be given on a daily basis. Staff training files showed that there is an ongoing development programme where individuals participate in safe working practice sessions and can access specialist subjects linked to meeting the specific needs of the residents within the home. The home employs eleven staff from India and South Africa. These individuals offer staff an insight into different cultures and informal discussion with the staff indicates they work well together as a team. Residents are able to make a limited choice of staff gender when deciding who they would like to deliver their care, as the home has three male staff who work night and day shifts, as well as the female members. Comments from the relatives and residents surveys indicate they are pleased with the care being given and have a good relationship with the staff. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is good. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans are in place for all residents and the four examined clearly set out the health, personal and social care needs identified for each person. The plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Risk assessments were seen to cover pressure sores, nutrition, moving/handling and activities of daily living. Information about the resident’s social interests, likes and dislikes, spiritual needs and wishes regarding death and dying are all included within the individuals care plan. Individual choices and decisions about how care is to be given were also well documented and for three individuals is very specific and detailed so staff can provide continuous care to meet their needs. Where necessary risk Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 11 management plans are in place to deal with verbal and physical aggression and self-harm. Input from the mental health team and consultant psychiatrists is clearly documented and residents have good access to outside clinics and professional advice. Three residents are receiving 1-1 care from the staff, and the individuals on duty who are responsible for this care ensure that an up to date record of activities completed and time spent with the resident is maintained. Comments from the resident and relative surveys are very positive about the care and medical support provided by the home. One individual said ‘I am completely satisfied and grateful to Prime Life for the care they give to my sister who requires total support, ‘ and a resident wrote that ‘there is always a doctor on hand if you should need one’. Three residents said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Entries in the care plan specify where individuals have dietary needs, including diabetes, supplement drinks and pureed diets. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. Information from the pre-inspection questionnaire and discussion with the deputy manager indicates that currently there are two residents with pressure sores, their wounds are documented in their care plans and wound care is given as appropriate. Checks of the wound care records indicates the staff ask the tissue viability nurse for advice, where needed, and they document each time the wound dressing is changed. The inspector recommended that the staff include a description of the wound at least once a week to ensure that its progress can be monitored and audited easily. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. At the moment no one living at the home is able to do so and all of the residents spoken to prefer to have staff administer their medication. A requirement and recommendation were made in the last inspection report (January 2006) for improvements to the medication records. The manager has acted on these and checks of the system at this visit showed the records to be up to date, accurate and well managed. Resident and relative comments show they are very satisfied with the care and support offered by the staff. Chats with the residents revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 12 Two individuals spoken to said ‘ the staff are lovely, they are always around to offer help and support when we need it and are very considerate of our feelings’. Observation of the staff at work showed they were patient, tactful and respectful when interacting with the residents. Talks to the staff demonstrated they have a good understanding of how to deliver care to individuals with mental health problems and insight into how specific conditions can affect an individual’s behaviour. Stoneleigh Care Home DS0000002806.V319236.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. Quality in this outcome area is good. Residents are provided with choice and diversity in the meals and activities provided by the home. Relatives and visitors are made welcome at the home and good links to the community enrich the residents social and leisure opportunities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a dedicated activity co-ordinator who runs a weekly activity programme in the dining room and lounges of the home. Residents are able to participate in a range of group and individual activities. Prime Life has a minibus, which the home can access twice a month, and talks to the staff indicate they would like to have their own transport as the residents get so much pleasure from the outings. Discussion with the residents reflected that they have a wide range of interests and likes/dislikes regarding activities and keeping busy. The majority of residents have access to a television in their own room and a number of them have radios and music equipment. One lady said ‘I like painting a lot, also anything to do with crafts’ another individual said ‘I enjoy going out for trips on the minibus’. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 14 Comments from the staff show that they would like to have the time to sit and talk to the residents and participate in more social interactions with them. Outside entertainers are booked to entertain the residents on a regular basis and the staff have started holding a film afternoon which is proving very popular. Good records are kept of all the social interactions going on in the home and evidence seen at this visit indicates that residents are encouraged to celebrate festivals such as Halloween, November the fifth and Christian events such as Birthdays, Easter and Christmas. Discussion with the deputy manager indicated that the home promotes awareness of other cultures through themed events, to date there has been an African day and Asian day with different foods on offer, flags on display and discussion about the different national costumes, lives and beliefs of other countries. There were a number of visitors to the home during the day of the visit and one individual said ‘ the staff are welcoming and look after my relative very well’. Open visiting hours at the home enable individuals to come at times suitable for the residents and which fit into their own busy work schedules. Information from the residents’ files indicates that there are a number of individuals who follow different spiritual faiths, including Catholic and Church of England. The deputy manager said that there are regular church services within the home and the catholic priest visits monthly to give communion to those who want to partake. Information about advocacy services is on display in the reception area of the home and includes leaflets made available to the residents and relatives by the manager. Discussion with the deputy manager indicated that no-one at the home is currently using an advocacy service, although these have been accessed in the past. Three residents spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. Residents spoken to are satisfied that they can access their personal allowances when needed. All the residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. Discussion with the residents showed that they are aware of their care plans and able to contribute to them and access them through their key workers. Observation of the lunchtime meal showed that this time of day is extremely busy, as some of the residents are restless and tend to wander around the dining room in between the meal courses. The kitchen staff are very organised and ensure that care staff, serving the food in the dining room, are made aware of whose lunch they are given and this enables them to be certain that every resident has received their meal. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 15 The cook caters for special diets such as soft, pureed and diabetic. Observation of the food going out to the dining room showed it to be well prepared and presented, and the kitchen staff had made an effort to provide soft/pureed diets in an attractive way. Discussion with three residents showed that they are satisfied with the food offered at mealtimes, one person said ‘we have lots of things to choose from and the food is always good’, another resident commented that ‘the food is hot, tasty and plenty of it’. The home has a large spacious dining room and staff were seen to offer residents the assistance/prompts they needed with eating and drinking. Fresh fruit and jugs of squash were seen in the dining room and lounges and residents said ‘we can help ourselves or the staff will get us a glass and those who need assistance have regular drinks offered’. Diet and fluid balance charts were seen in the dining room/kitchen, these were up to date and completed by staff throughout the day. Nutritional risk assessments are completed for all residents and kept in their care plans, individuals are weighed regularly and have access to a dietician if the staff are concerned about their nutritional wellbeing. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the manager acts quickly on any issues raised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Checks of the complaints record indicate the home has dealt with two complaints since the last inspection, details of the actions taken and responses to the complainants were seen and the manager has resolved the issues. The home has a clear and simple complaints procedure that residents, relatives and staff are aware of and are confident of using if needed. This policy is on display within the home. Two residents said that they were aware of the procedure and confident that if they had any concerns these would be listened to and acted on by the manager. The staff on duty displayed a good understanding of the vulnerable adults procedure and three residents spoken to said they ‘felt safe at the home’. Staff training files show that Protection of Vulnerable Adults from Abuse training has taken place and is an ongoing process, and information from the staff surveys indicates they are aware of the whistle blowing procedure. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 17 The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, management of service user monies and finances, physical intervention and restraint. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 18 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, 22, 24 and 26. Quality in this outcome area is good. Some aspects of the environment require improvement to ensure the residents are provided with an attractive and pleasant place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information from a quality audit conducted by Louise Hayward of Prime Life, indicates that ‘Stoneleigh is an old home and therefore needs a constant refurbishment schedule. The company has identified land in Scunthorpe as suitable for a new home and planning consent is being waited for. Building is due to commence November/December 2006 and will take approximately 10 months, with an opening date of September 2007’. Walking around the home there were signs that further refurbishment is needed. Stained carpets were seen in the corridors near to the medication room, the music room, stairways and the television room. Discussion with the deputy manager indicated that the domestic staff clean these areas regularly Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 19 but the stains are permanent. Corridors and doorways are scuffed due to damage from wheelchairs and paintwork in these areas needs redoing. The upstairs bathroom needs some attention as the end panel to the bath is held on with tape, the bath itself is stained and the paintwork on the walls is flaking in areas. There were some malodours noted in certain areas of the home despite the cleaners being seen to be shampooing carpets and deep cleaning rooms. The provider should consider replacing the stained carpets to improve the appearance of the communal areas for the residents and to reduce the odours in the home. Discussion with the deputy indicated that a new suction machine has been provided since the last visit in January 2006, the laundry has had a new washing machine and two bedrooms have new flooring on order. Residents are able to walk around the home and go out into the secure, safe garden area, this regular walking aids their overall mobility and promotes their independence. Observation of the premises shows that its facilities can meet the needs of disabled individuals. Doorways to bedrooms, communal space, corridors and toilet/bathing facilities are wide enough for people in wheelchairs or with walking frames to pass by comfortably. The home is built on two floors with flat walkways inside and out, providing safe and secure footing for people with limited mobility. Access to the upper floors is by use of a staircase or the passenger lift. Discussion with the staff indicates that there is a wide range of equipment provided to help with the moving and handling of the residents and to encourage their independence within the home. This includes mobile hoists, bath hoists, stand aids, slide sheets, moving belts and handrails. Two residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more at home’. The rooms are individually decorated and supplied with sufficient furnishings to meet the needs of the residents. Double rooms are provided with privacy curtains that can be drawn across the room when individuals are receiving personal care. The provision of bedroom door locks and keys has only be extended to five rooms at this time, although the deputy manager said the other rooms could have this facility if requested and residents were risk assessed as suitable for the provision of a key. Overall the environment is warm and comfortable with few malodours present. Information from the surveys indicates that the residents are satisfied with the laundry service provided by the home. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. The standards of recruitment, induction and training of staff are good with appropriate employment checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that residents are protected from risk and looked after by motivated and knowledgeable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the staffing rotas shows that there are two nurses and six care staff on duty from 8am to 2pm, one nurse and six care staff from 2pm to 8pm and one nurse and three care staff at night. Additional full time staff are employed to cover the 1-1 time needed by three residents, these hours are recorded on a separate rota. Ancillary staff are employed for the kitchen, laundry and domestic posts within the home and the activity co-ordinator is also additional to the care staff. Information from the pre-inspection questionnaire about the number of staffing hours provided, and information gathered during the inspection about the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. There is an induction and foundation course for new members of staff, and 43 of the care staff have achieved an NVQ 2 or 3. The home provides a Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 21 mandatory staff-training programme and additional, more specialised training that reflects the different care needs of the client group. Information given by the manager in the pre-inspection questionnaire indicates that staff have access to training around equality, diversity and disability rights and this is being delivered by Hull College. Information in the staff training files and discussion with the staff indicates uptake of training has been good over the past 12 months and there is a staff training matrix in place to monitor this. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the deputy manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The deputy manager said that the home has tried to recruit more male carers in the past as the management team is aware that the majority of staff are female, but this has proved difficult as there have been few suitable applicants. She is aware that this may affect resident’s wishes regarding gender choice for giving of personal care, and this is discussed before an individual is offered a placement at the home. Comments from the deputy manager indicate that the majority of the residents are from a white British background, but the home is able to offer a range of services when they are approached from someone of another culture or ethnic group. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38. Quality in this outcome area is good. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of residents, staff and relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although the manager for the home was not present at this visit, information available to the Commission indicates that she has achieved her Registered Managers Award and is a qualified Mental Health nurse with an active PIN. She has been the manager of the home for twelve years and has a good understanding of the needs of this specific client group. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 23 The home has achieved the North Lincolnshire Council’s Gold Star Award for Quality Assurance and also has Investors In People status. The home has a Prime Life Limited Quality Assurance system in place and audits of the service are carried out on a regular basis. Meetings for the staff and residents are taking place; minutes are kept and are available for any interested parties to read. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. A requirement made in the last inspection report of January 2006 was for information from the questionnaires to be analysed and put into an annual development plan. This documents the comments received and shows how the home has altered or developed its service as a result of this input from those using the service. Information shown to the inspector at this visit indicates that the manager is beginning to pull this information together to produce an annual development plan, although this is not yet completed. The inspector will look at this again at the next inspection and the requirement will remain on this report. Checks of the financial system indicate that the home continues to keep accurate and up to date records for all the residents. The records are computerised and maintained on a daily basis by the administrator of the home. All residents have their own personal allowance account, and personnel from the Company’s Head Office (regularly throughout the year) independently audit these. Information given to the inspector indicated that the home manager is an appointee for ten residents, one individual looks after his/her own financial affairs, one person has a solicitor acting in their stead, one has the North Lincolnshire Council as their representative and twenty four other individuals have their families looking after their finances. Relatives who are unable to visit very often are asked to send spending money for the residents as and when their personal allowance accounts show their monies are low. These requests from the home are accompanied by a print out of the resident’s account. The home only keeps a limited amount of money within the safe, surplus monies are kept in a communal resident account, which does not pay individuals any interest. The inspector recommended at the last visit in January 2006 that this information is put into the Service User Guide, so all those coming into the home are aware of the homes arrangement and can decide if they wish to make their own. This does not appear to have been implemented so the recommendation remains in this report. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 24 No progress has been made to change the accident book format since the last inspection (January 2006). Accident books are filled in appropriately, but the format currently in use does not comply with date protection legislation. The manager should consider getting a more up to date version that has tear off paperwork that can be filed away and kept confidential. This was a recommendation in the January 2006 report and will remain so in this report. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP19 OP33 Regulation 23 24 Requirement The provider must ensure that all parts of the home are kept clean and reasonably decorated. There must be an annual development plan for the home, based on a systematic cycle of planning, action and review. (Given timescale of 10/04/06 was not met). Timescale for action 01/04/07 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP19 OP24 Good Practice Recommendations The staff should include a description of the wound on the wound care chart, at least once a week to ensure that its progress can be monitored and audited easily. The provider should consider replacing the stained carpets to improve the appearance of the communal areas for the residents and to reduce the odours in the home. All bedroom doors should be fitted with a suitable lock to ensure resident’s belongings are kept safe, and those residents who are assessed as able should be given a key. DS0000002806.V319236.R01.S.doc Version 5.2 Page 27 Stoneleigh Care Home 4. 5. OP35 OP38 The manager should put information, about how resident’s monies are held in a none interest bearing account, within the Service User Guide. Accident books should be purchased, which meet the Data Protection Legislation. Stoneleigh Care Home DS0000002806.V319236.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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.V319236.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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