Inspection on 23/01/08 for Stoneleigh House

This inspection was carried out on 23rd January 2008.

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

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 03/09/07

Stoneleigh House 28/07/07

Stoneleigh House 18/05/06

Stoneleigh House 13/10/05

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 Buckley Unannounced Inspection 23rd January 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 House DS0000005521.V357142.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 House DS0000005521.V357142.R01.S.doc Version 5.2 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) 0161 624 5983 0161 678 2158 masterpalm@masterpalm.co.uk Masterpalm Properties Limited Post Vacant 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.V357142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - code PC, to people of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, (maximum number of places: 23); Dementia over 65 years of age - Code DE (E) (maximum number of places: 8). The maximum number of people who can be accommodated is: 31. 12th December 2007 Date of last inspection 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 en-suite facilities. Of the 26 rooms, two share an adjoining en-suite. There are two shared rooms, both of which have en-suite. Communal facilities include three large lounges, one of which is an allocated smoking area and a large dining room. Fees range from £335.00 to £348.00. Stoneleigh House DS0000005521.V357142.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 1 star. This means the people who use this service experience adequate quality outcomes This was the second key inspection that included a site visit to the home. The Commission for Social Care pharmacist also undertook a random inspection on the 13th December 2007. The home has been without a registered manager for several months. At the time of this inspection, the deputy manager was acting in the role of manager. The home was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The acting manager, relatives and a member of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from professionals and people in the home are included, together with questionnaires returned from staff. What the service does well: Care plans in the home reflected people’s assessed needs and were reviewed on a regular basis. Staff felt involved with decision making in the home through regular staff meetings when care practices are discussed and improvements that may be needed. Staff reported in questionnaires they felt the acting manager operated in an open and inclusive manner. Meetings had just been introduced to gain the views of people in the home. People were positive about improvements made, saying, “If I ring the bell at night staff are there immediately”. Another said “I am very independent I help myself to a shower when I want; staff always treat me with respect.” People said the cook goes round in the morning to see what people want off the menu. One said, “The food is very good and staff always ask what you want.” Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the acting manager had made good progress in addressing issues, there still remained some concerns in the outcome for people, especially in relation to their personal appearance. Staff meeting minutes demonstrated that the acting manager also recognised this and was in the process of introducing a key worker system to promote accountability. This system needs to be monitored closely to ensure personal care standards are maintained through a sustained period of management. Staff supervision needs to commence as an aid to monitoring standards. Medication storage, especially controlled drugs, needs to be held securely until returned to the pharmacist. The recording of these should be booked in on receipt and out when returned to the pharmacist, in order to maintain an audit system. Variable dosages must be recorded as to what dose was given and signed for at the point of administration. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 7 Although good progress had been made in staff training, the number of staff who have achieved NVQ level 2 needs to be increased. 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 House DS0000005521.V357142.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 House DS0000005521.V357142.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): Standard 3 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The admission assessment and review process ensures people’s needs are met. EVIDENCE: The acting manager said the statement of purpose was being upgraded to reflect changes in the facilities and services; most of this document had been completed at the time of this inspection. There had been no new admissions to the home since the last inspection. Four case files were looked at; all had admission assessments in place. For those people who had been in the home a long time, there was evidence that the placing authority held regular reviews to ensure the home was still meetings people’s needs. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 10 In these instances, issues identified on the review were recorded in care planning. Stoneleigh House DS0000005521.V357142.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): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Improvements in care planning promote the health and wellbeing of people in the home. The introduction of a key worker system will ensure accountability within the staff team and maintain the dignity of people in the home. Consistency needs to be maintained in medication procedures to ensure people are not put at risk. EVIDENCE: There has been an improvement in care planning and record keeping since the last inspection. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 12 Four case files were looked at in depth and were found to have detailed recordings of people’s needs. There was evidence that when weight loss had been identified, a nutritional screening tool was put in place (MUST) and weight monitored regularly. Food and drinks taken were recorded providing a clear picture for professionals should this be required. Instruction to staff on preparing people’s food was also recorded, for example, ‘requires food cutting up or any specific aids needed.’ Care plans also referred to the maintenance of people’s privacy and dignity. People who were at risk of falls had been referred to the falls prevention nurse and risk assessments were in place. Accidents that had taken place were documented in both the accident book and daily notes, with adjustments to care planning where required. There was evidence that the acting manager had requested a pressure mat for a person who was considered high risk. Equipment available for use included a hoist, three moving and handling belts, two slide sheets, turntable and sitting weighing scales. Of the files examined, there was only one issue that had not been transferred into care planning and this was brought to the acting manager’s attention. This related to a person with sensory impairment and the acting manager said they would address this right away. Comments from people in the home included “Staff treat me very well”, “I can have a bath whenever I want, I just tell the girls to do it”, “Staff are very good they do not mess you about” also “If I ring the bell at night staff are there immediately.” Not everyone had a photo on file but the acting manager had a list pinned up of whom to obtain photos for. One person said “I am very independent and help myself to a shower when I want and staff always treat me with respect.” There was evidence that staff had received training in continence care, dementia, challenging behaviour, moving and handling and infection control. The falls prevention nurse had also been contacted to arrange training. We interviewed a district nurse who was visiting at the time of this inspection. The nurse said that communication had improved and that they were pleased that a treatment room has now been provided. People’s skin integrity had also improved and staff in the home took on board advice given to them. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 13 Although there had been improvements in general, with staff training and recording care planning, we still had some concerns in relation to personal care. Several people looked dishevelled. This was discussed with the acting manager who had also recognised this and produced minutes from a recently called staff meeting which informed staff that to ensure people’s needs were met, a key worker system was to be implemented with staff being allocated tasks relating to personal care on a daily basis to promote accountability. This would then be monitored by the manager and deputy manager to ensure the personal care needs and presentation of people remained positive and maintained their privacy and dignity while reflecting personal choice. One person said “I have had a shower today but I like my daughter to do my nails.” There was evidence of professionals’ visits and that people had a doctor when needed. One person said “I have had my nails done by the podiatrist today”. Improvements had been made in medication procedures since the last inspection. Four day staff and three night staff had received training in the administration of medication and only trained staff have access to the medication storage area. The acting manager had started to place photos of people on medication files for easy identification – this was still ongoing at the time of this inspection. Medication policies and procedures had been upgraded and the reasons for any changes or omissions to the administration of medication were recorded on the back of recording sheets in some instances. Risk assessments had been put in place for people who self medicate. These would benefit from more in-depth information being recorded. The acting manager and deputy manager are responsible for conducting audits of the medication system. There was room for improvement in the recording of variable dosages, which need to be specific on the quantity provided and signed for at the point of administration. The recording of controlled drugs needs to reflect the amount returned and received to demonstrate the correct balance. Any controlled drugs no longer required need to be stored as controlled drugs until returned to the pharmacists. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Improvements made to the dining experience and activities provide people with choice and an opportunity for fulfilment in their daily lives. The introduction of a key worker system will promote staff accountability in maintaining the dignity of people in the home. EVIDENCE: Since the last inspection an activity co-ordinator has been employed for 2.5 hours a day, five days a week. The acting manager maintained a record of activities in the home. Care planning includes a “getting to know you sheet” which records people’s preferences. Where these had been completed, information was provided for staff on people’s preferences. This was a new aspect of care planning recently introduced, so not all the forms had been completed. There was evidence that local churches visit the home to give communion. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 15 The needs of people with complex needs should be addressed. For example, people with sensory impairment should have access to talking books or recordings of a local paper. The acting manager said the introduction of the key worker systems would make staff more accountable for people’s daily life experiences in order to provide a more fulfilling life for people in the home. This also applies to people’s personal appearance that could be improved, as mentioned earlier. The acting manager said there had been a problem with finding a hairdresser to undertake a regular commitment. The dining experience for people had improved, with the acting manager looking at further ways to make the experience more enjoyable for people in the home. We (The Commission) dined with people who were offered a choice of pork steak and vegetables or corned beef hash. There was a choice of seating areas and some people chose to sit in the lounge dining area. We spoke to the cook who was reviewing the menus; she said that part of her role is to ask people in the morning their preference of meals. Two people said, “The food is very good and staff always ask you what you want”. One person said, “The cook brings a newspaper and gives it me to read. I would like to go out and buy my own newspapers and trousers if I could.” Another person said, “I can go to bed and get up when I want.” Also “Clothes always come back from the laundry ok but I do not like the washing powder.” People discussed activities in the home saying, “It was really nice in November, we had fireworks.” People in the home had been invited to the rotary club lunch; some had chosen to go and they had really enjoyed this. Stoneleigh House DS0000005521.V357142.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): Standards 16, 17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People feel able to express their concerns and the acting manager acts on concerns appropriately. Staff receive training in the protection of vulnerable adults, ensuring people are not placed at risk. EVIDENCE: The complaints procedure is available in the main entrance for all to see. People knew who to talk to if they had any concerns and said they felt able to discuss any issue. One person said “I would complain if I were not happy” and another said “I would see the manager if I were not happy.” A record of complaints is maintained. The CSCI had not received any complaints but the home had received three. These included one relative complaining over falls sustained by the family member. These had been recorded and the acting manager had called a review in order to discuss the matter with professionals. The second complaint was not keeping the family informed of changes and the third was regarding financial outgoings. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 17 On each occasion the acting manager had addressed these and recorded outcomes. For example, a balanced sheet for the person’s expenditure was provided. Evidence was provided that Oldham Social Services training department had been contacted to provide staff with training in the protection of vulnerable adults. Seven staff had completed training in October 2007. Further training had been arranged for 27th February 2008. Stoneleigh House DS0000005521.V357142.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): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People are provided with a comfortable, clean environment, which they are encouraged to personalise. The infiltration of smoke into other parts of the home will reduce the comfort of people in the home if not addressed. EVIDENCE: All communal areas and a selection of bedrooms were inspected. A new carpet had been provided in one of the three lounges and new floor covering in one of the downstairs toilets. One of the lounges is an allocated smoking area. This area had a strong odour of cigarette smoke that infiltrated into other areas of the home. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 19 Certain carpeted areas were worn and threadbare, posing a possible risk to people in the home. These areas should be made safe until a replacement is available. The acting manager said they complete an inventory of work needed to be done by the owners, the date when requested and when completed. However, it was evidenced that little had been done by the owners to address minor repairs in the home. In one lounge the TV had only a small screen, which made it difficult for people to see. Many of the chairs, especially in the smoking area, were dirty or worn. The manager produced evidence of a delivery of chairs the following week to replace these. The standard of cleanliness and hygiene in the home was good and people were provided with clean and presentable rooms that they had personalised. One person said “I like to spend a lot of time in my room, it is warm, comfortable and I have a nice view.” New fire escapes had been provided and magnetic door closures. Stoneleigh House DS0000005521.V357142.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): Standards 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The number of staff employed is sufficient to meet the needs of people. Recruitment procedures are robust providing protection for people. EVIDENCE: Examination of the staff duty rota showed that sufficient staff were on duty to meet the needs of people in the home. At the time of this inspection there was a vacancy for a weekend cook, which the manager had recruited to and was awaiting clearance of references and Criminal Record Bureau checks. Each member of staff had a training file. Training made available to them included dementia care, infection control, protection of vulnerable adults and health and safety. Moving and handling training had also taken place, with a course arranged for 24th January 2008. This information was on the notice board, requesting staff to attend. The number of staff trained to NVQ level 2 falls short of the 50 required. There was evidence that the home is working toward this. The total number of staff is 23, two staff have completed NVQ level 3 and three have enrolled. Seven staff have completed NVQ level 2 and a further eight have enrolled. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 21 Staff induction is accessed through Oldham Social Service training department, in line with Skills for care. Staff receive a short introduction into the home with the manager or deputy in order to orientate them with the home and health and safety issues. The acting manager said that during the first week new staff are supernumerary and shadow trained staff until deemed competent. No new care staff had been recruited since the last inspection. There was evidence that recruitment procedures included two references, criminal reference bureau checks with any gaps in work history being explored and recorded. One person said “Staff are great, if you ask them anything they will do it for you.” Three staff questionnaires were returned; all said they received training relevant to their role. One said we receive in-house training and also outside agency training. Staff at interview demonstrated a good knowledge of people in their care and maintaining people’s privacy and dignity. Stoneleigh House DS0000005521.V357142.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): Standards 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. A sustained period of consistent management needs to be maintained in order to address care practices and maintain positive outcomes for people in the home. Systems are in place to safeguard personal finances. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 23 EVIDENCE: Stoneleigh House has been without a registered manager for a period of time. Recruitment had taken place, with the post being filled for a short time, but, due to unforeseen circumstances, the deputy manager is at present acting in the post of manager. They have experience in care and management and have completed NVQ level 4 and are also a moving and handling facilitator. They have enrolled to undertake the registered manager’s award. The deputy manager is qualified to NVQ level 3 and provides management support in the acting manager’s absence. Nine requirements were made on the previous inspection and all but one had been addressed. Of the 13 good practice recommendations made, all but four had been completed, with the acting manager working towards addressing the remaining issues. Staff supervision had not yet started. The acting manager said this was due to be introduced, along with the key worker system in order to promote staff accountability. One staff questionnaire said, “The deputy manager is organising staff supervision.” There was evidence that people in the home are consulted through residents meetings. Staff meetings had been held, with minutes being available for the 11th January 2008 meeting, where the previous inspection report and the improvements required were discussed. Staff were informed that either their duties were not clear or they were not undertaking personal care tasks to the required standard. Therefore, a key worker system would be introduced where it is hoped that choices of people in the home would be promoted. Other topics in the meeting included confidentially and correctly completing records. Questionnaires had been sent out to professionals in November 2007 but none had been returned at the time of this inspection. A visiting district nurse said, “There have been big improvements in the management of the home”. Staff commented saying, “The manager is more open and inclusive” and “The manager is looking at a key worker system which we think will be good.” Health and safety files were maintained and equipment had been serviced. Requirements made by the fire brigade had been completed but staff had not received recent fire drill training. Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 24 One staff questionnaire, in relation to what the home could do better, stated “a greater level of communication”. All questionnaires stated staff met with management on a regular basis. The financial records of four people were examined and found to have evidence of receipts and expenditure, with balances matching that held by the home for people. Stoneleigh House DS0000005521.V357142.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 X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Stoneleigh House DS0000005521.V357142.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 Standard OP7 Regulation 15 Requirement All assessed needs must be reflected in care planning in order for staff to provide adequate care. For example, people with sensory problems. Personal care and presentation of people in the home must be improved to maintain their dignity. Medication must be stored safely with controlled drugs being held securely until such a time they are returned to the pharmacy. Variable dosages of medication must be recorded as to what dose has been given and recorded at the point of administration. The recording of controlled drugs must show the quantity received and returned to the pharmacy. Timescale for action 28/02/08 2 OP8 15 28/02/08 3 OP9 13(2) 28/02/08 Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 27 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 4 5 6 Refer to Standard OP28 Good Practice Recommendations Ensure staff progress on the NVQ training is monitored to maintain at least a minimum 50 of care staff with NVQ II or above. Risk assessments for people who self medicate would benefit from additional detail on their competence to do so. Review ways of preventing smoke from the smoking lounge infiltrating into non-smoking areas. Make safe areas where the carpet has frayed in order to prevent accidents in the home. Staff routines and accountability should be revised to ensure people’s personal hygiene is maintained to a good standard. The registered person should ensure that the home is visited at least once a month, when a report is written on the running of the home in line with Regulation 26 of the Care Homes Regulations 2001. This report must be available for inspection. Staff supervision should be undertaken on a regular basis and recorded to ensure training needs can be identified. OP9 OP19 OP26 OP30 OP31 7 OP36 Stoneleigh House DS0000005521.V357142.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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. 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