Inspection on 13/10/05 for Stoneleigh House

This inspection was carried out on 13th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Stoneleigh House 17/06/09

Stoneleigh House 23/01/08

Stoneleigh House 03/09/07

Stoneleigh House 28/07/07

Stoneleigh House 18/05/06

Stoneleigh House 09/06/05

Stoneleigh House 24/11/04

Stoneleigh House 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Stoneleigh House Cooper Street Springhead Oldham OL4 4QS Lead Inspector Sandra Bennett Unannounced Inspection 13th October 2005 10:18 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 House DS0000005521.V256010.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stoneleigh House Address Cooper Street Springhead Oldham OL4 4QS 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) 01616245983 0161 678 2158 Masterpalm Properties Limited Joan Mills Care Home 31 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (23) of places Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user to include up to 23 OP up to 8 DE (E) Date of last inspection 9th June 2005 Brief Description of the Service: Stoneleigh House is a detached property in a semi rural location. It is situated close to public transport and local amenities. To access the property service users have to manage a small incline from the main road. The outside of the property is well maintained with landscaped gardens and views over the local area. Accommodation is provided in 27 single rooms, of which 26 have an ensuite facility. Of the 26 rooms two share an adjoining ensuite. There are two shared rooms, both of which have ensuite. Communal facilities include three large lounges one of which is an allocated smoking area and a large dining room. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This scheduled inspection took place on the 13/10/05. Time was spent talking to eight service users, one relative and three staff. The care plans for four service users were looked at in detail, looking at their experience in the home from the time of their admission to the present day. Records of care were examined along with staff duty rotas, personnel files, financial records and medication records. Ten service users questionnaires were returned, none had been returned at the time of writing this report. What the service does well: What has improved since the last inspection? Regular formal staff supervision has commenced since the last inspection. Residents said they were looking forward to increased activities through the appointment of an activities co-ordinator and that they had been consulted on their preferred activities. Some redecoration has taken place in resident’s rooms, which they were pleased about. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 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. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 5 A detailed assessment of service user needs prior to entering the home should be obtained. Information given to residents prior to admission needs to be reviewed and reflect any additional charges to ensure an informed choice can be made. EVIDENCE: Three residents newly admitted into the home reported that information was given to their relatives prior to their admission and that they made several visits to the home to see if they would be able to settle into the home. One resident reported that they had been in other homes and did not feel comfortable has they did at Stoneleigh House. Examination of the information given to service users found that there was a failure to explain any additional charges for accommodation and what the resident may expect for the additional charges. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 9 Individual records are kept for each resident. On inspection of the three recent admission’s files were found to be lacking in resident initial assessment with aspects of paperwork and care planning incomplete. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. A professional assessment had not always been sought prior to resident’s admission to the home. The health care needs of service users were not consistently recorded. Procedures for the storage, recording and handling of medication needed to be reviewed. Resident’s records were held securely. EVIDENCE: In some instances it was difficult to assess if residents needs were being met appropriately because of the lack of professionals assessment prior to entering the home. In one instance a resident had been admitted outside of the home’s categories of registration. The needs of this resident would require additional staff training in the home. An application to amend the homes categories of registration should be completed and returned to the CSCI for processing. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 11 The recording system was in the process of change. As a result of this process those files completed had full details of healthcare needs and professional visits, all other files not completed must be brought into line in order to provide a comprehensive system. Omissions were noted on certain files in relation to reviews of care plans, and dates and signatures of persons completing the care plans. Staff at interview discussed weight loss of some residents, no evidence of these concerns was found in the recording or review of the care plan of these residents. Accidents sustained by service users had been fully recorded and actions followed through into daily reports and care planning. In one instance a service user had been provided with bed rails without evidence of consultation having occurred with health professionals as to the appropriateness of rails. Examination of medication storage and administration found that in one instance a resident was being given medication prescribed as and when necessary on a regular basis, and another instance when medication prescribed three times a day being administered as and when necessary. In these instances consultation should take place with the residents GP to review their medication to ensure residents receive the appropriate treatment. The homely remedies policy did not give sufficient detail of what each service would be allowed to take after consultation with their GPs. Senior staff had all received training in the administration of medication, observed practices on the day of inspection were deemed to be correct. Several items of medication were stored in a fridge the temperature of which had not been recorded. Records showed that some resident were applying topical lotions themselves, in these instances a risk assessment should be completed to ensure residents are capable of managing their medication. Resident’s records were stored away from public gaze. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 and 15. Meals were nutritional and balanced and offered a varied diet for residents. Routines in the home were flexible to meet the needs of residents. Improvements had been made in the provision of social activities for residents. EVIDENCE: On the day of inspection some residents choose to get up late and were having breakfast at 9.30am as was their preference. The inspector dined with residents who commented how much they enjoyed the food and that choices were available to them. Interviews with the cook found that they are involved in the resident’s assessments or interviewed them on admission as to their likes and dislikes. A record was kept in the kitchen of resident’s dietary needs and any special requirements. Tables were set attractively, one resident commented on the flowers on the table saying “we always have flowers on the table” with another commenting on their specific diet which the cook strived to “make my meal like other meals being presented.” Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 13 Three of the residents interviewed described their routine throughout the day and commented on the new activity co-ordinator allocated 16 hours a week to provided activities inside and out of the home. Residents commented that they were really looking forward to this. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents were confident they could raise concerns with staff and their complaints would be listened to. EVIDENCE: Residents interviewed were confident that their complaints would be listened to and that they would feel comfortable in raising any concerns. Examples were given of not receiving monies on time, which were not related to administrative procedures in the home. However they were sure that the manager was doing as much as possible to rectify the issue. The complaints procedure had been amended to reflect the correct address of the CSCI should a resident feel dissatisfied with any aspect of the home. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,24 and 26. The home has continued to make improvements in the environment, however certain areas of the environment posed a risk to resident’s safety. Resident’s rooms were personalised and free from odour. EVIDENCE: Since the last inspection the home has continued with their redecoration programme. A number of other areas still require attention, in particular carpeting on the stairs and landings, which is worn. This not only looks unsightly but also poses a trip hazard in the near future. This carpeting must be repaired or replaced to maintain safety. Some bedrooms still required redecorating or replacement carpets. The refurbishment plan was unavailable for inspection; this must be made available and revised to reflect outstanding issues identified by the manager. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 16 Many resident’s bedrooms had been personalised giving a homely appearance. Although the home presented clean and without odour a shortfall in ancillary staff had resulted in the cleaning of chairs being neglected. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Staff recruitment, training and induction were not robust enough to provide adequate protection for service users. The lack of ancillary staff over the weekend period compromised the safety and hygiene standards in the home. The number of staff who holds NVQ needs to be increased. EVIDENCE: A number of staff had completed NVQ2 training however this still did not meet the required number of 50 . A staff induction was in place, which was not sufficient to instruct staff on care principles, moving and handing techniques and specialist areas such as dementia care. One resident had been admitted into the home with mental health problems but staff had not been provided with any to meet the needs of this resident. Examination of duty rotas, interviews with staff found that on many occasions there had been shortfall of care and ancillary staff especially over the weekend period. On these occasions care staff have to undertake housekeeping and laundry duties, which could result in residents needs not being met Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 18 Three files of newly recruited staff were examined. No application for a Criminal Record Bureau check was on file or evidence that a request for a POVA first check had been made. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. The lack of a permanent manager in post has resulted in a loss of direction for staff and accountability in care practices. The introduction of staff meetings is enabling issues in the home to be addressed. Further developments are needed to the recording systems and policies and procedures in the home. EVIDENCE: At the time of this inspection a new manger had been in post since the beginning of August 2005 but has yet to make an application for registration to the Commission. Although the manager had a number of years experience in care and is qualified to NVQ level 3 she must now complete the Registered Mangers Award to demonstrate her ability to mange the home. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 20 Residents and visitors made positive comments about the approachability of the manger and staff team. There were some examples of poor communication and staff being unclear what is expected of them. Interviews with staff showed there was no system in place for task allocation although a handover did take place at change of shift on the care needs of service users. A communication book was available for staff to write the care needs required by service users. This method does not promote accountability in the home and may lead to tasks being overlooked, putting service users at risk. The manger reported that they were presently addressing these issues, through staff supervision and staff meetings. A staff meeting had been arranged prior to the inspection to address certain issues. Staff reported that they felt the meeting had been productive and clarified issues. Residents meetings need to be established to ensure the views of residents are obtained. Examination of service users financial records showed the monies held on behalf of service users correlated with the recorded amount. There was evidence on staff files that appropriate health and safety training alongside infection control and moving and handling had taken place. Additional training needs to take place in relation to the mental health needs of residents. As mentioned previously in this report there has been omissions and errors in the recording of resident’s care assessment details and medication records. There was also a lack compliance with the requirements in relation to CRB checks on staff. Although the owners Stoneleigh House visit the home on a very regular basis, there was no evidence that they reviewed the standards of care delivered to service users. Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 21 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 2 x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x X 2 X X X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 3 3 3 2 2 Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4/5 Requirement The registered person must ensure residents and their representatives are provided with information on the facilities and services and any reason for any additional charges. (Timescale of 31/9/05 not met) The registered person must obtain an assessment for each residents prior to their admission into the home. The registered person must ensure that care plans of residents are completed fully, reflect the assessment of needs and are signed and dated by the person completing them. The registered person must ensure that consultation takes place with health care professionals on the use of cot sides and reflected in care planning. Residents weight charts must be maintained and nutritional screening undertaken if identified as a need. The registered person must ensure that medication is administered as prescribed by DS0000005521.V256010.R01.S.doc Timescale for action 31/12/05 2 OP3OP7OP 37OP38 OP7OP37O P38 14 31/10/05 3 15 31/12/05 4 OP8OP38 12 31/12/05 5 OP9 13(2) 13/10/05 Stoneleigh House Version 5.0 Page 23 the residents GP and periodically reviewed. The registered person must ensure that all reviews of resident’s medications are recorded on the individual resident’s care plan. The registered person must ensure that a record of the temperature of the medication fridge is maintained. The registered person must ensure that a risk assessment is completed for those resident who self medicate. The registered person must ensure that the policy on selfmedication must be reviewed to reflect homely remedies, which can be taken for each resident after consultation with their GP. 6 OP26OP27 OP38 OP29OP38 18(1) The registered person must 31/10/05 ensure that sufficient staff are on duty at all times to meet the needs of the residents. The registered person must 31/10/05 ensure that criminal records bureau checks are obtained for all staff before commencement of their employment. The registered person must 21/12/05 ensure that the number of staff who holds NVQ2 is increased to 50 . The registered person must ensure that training must be provided to all staff to meet the special needs of all service users. 7 19 schedule 2 18 (1) 8 OP28OP30 OP38 Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 24 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 OP20 OP31 Good Practice Recommendations The registered person should produce a refurbishment plan, which reflects work to be undertaken in the environment. The registered person should ensure that an application to register the manger is forwarded to the CSCI for processing. The registered person should ensure that a formal process for daily allocation of care tasks care and domestic routines is introduced to promote accountability in the home. The registered person should ensure that staff and residents meetings are formally introduced and recorded 3 OP32OP33 Stoneleigh House DS0000005521.V256010.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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