Inspection on 03/09/07 for Stoneleigh House

This inspection was carried out on 3rd September 2007.

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 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 3rd September 2007 09:00 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.V346972.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.V346972.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 None registered at present 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.V346972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 31 to include: *up to 23 service users in the category of OP (Old age not falling within any other category); *up to 8 service users in the category of DE(E) (Dementia over 65 years of age). The service must employ at all times a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 18th May 2006 2. 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 an 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.V346972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home. 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. A CSCI pharmacist, who looked at medication policies, procedures and administration, accompanied the inspector. During the site visit information was taken from various sources, which including observing care practices and talking to people in the home. The manager, relatives and some members 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 questionnaires returned from residents and their relatives are also included in this report. The manager had only been in post eight weeks at the time of this inspection and is not yet registered with the CSCI. The manager had completed the Annual Quality Assurance Assessment (AQAA) required by the CSCI. Although this document needed more information on assessments, care practices and development, the manager was able to demonstrate an awareness of areas that needed improvement, for example, care planning and how this would be addressed. What the service does well: Of the files examined, a professional assessment of people’s needs had been obtained prior to their admission. From this, people’s likes and dislikes were transferred into care planning, so that staff knew what residents liked and disliked, although this had not been done for everyone. Conflicting views were obtained through questionnaires, for example, one person said, “You can ask for things but nothing ever gets done” while another said “Stoneleigh House has been through a very unsettled period this year, I felt the care fell short of my expectations during this period, however, since the new full time manageress took over, new staff have been arriving and the home has improved greatly; hope it keeps that way.” Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 6 Other comments from relatives and people who live in the home include, “Staff are very nice to me”, “I can go to bed and get up when I want” and “Staff always keep me informed of doctors’ visits”. What has improved since the last inspection? What they could do better: Serious issues were noted in the policies, procedures, ordering, storing, administration and recording of medication. The manger was required to take immediate action on these issues. Another concern was the failure to transfer all information on people’s assessed needs into care planning which may result in their needs not being met. Case files contained varying amounts of information, which may be misleading to staff. Files should be streamlined and maintained in a good order. Although staff training was being addressed, this must also include training in the protection of vulnerable adults and diseases associated with old age. The number of qualified staff needs to be increased to 50 . Daily life and the delivery of personal care need to be improved through a review of staff routines, in order to promote staff accountability.. Additional stimulation and activity for people were required. One person said, “I fill my time just watching television; I would join in activities if there were any.” The manager said that they had advertised for an activities co-ordinator. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 7 Staff recruitment procedures need to be improved in order to provide protection for people in the home. Quality monitoring systems need to be enhanced to include the views of relatives and professionals alongside people living in the home. The registered person must 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. This will demonstrate that when the owner or his representative visit, they look at the things we believe are important and talk to people living and working in the home. A period of sustained management needs to be maintained in order to address issues identified in this report, paying particular attention to recruitment policies and procedures, delivery of personal care and the promotion of staff accountability; also, recording and medication systems. 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.V346972.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.V346972.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. An assessment of need is obtained from professionals prior to people being admitted into the home, ensuring their needs can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three case files were examined in depth and were found to contain an assessment of need from professionals prior to admission to the home. Progress has been made in reviewing the statement of purpose and service user guide. These documents must also include advice on where in the home people can read the Commission for Social Care Inspection’s report. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 10 Stoneleigh House does not provide intermediate care. Stoneleigh House DS0000005521.V346972.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 poor. Inconsistent documentation of the care planning has the potential to leave people with unmet needs. Medication procedures do not offer a robust framework to protect the interests of people. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A new manager had been in post approximately eight weeks at the time of the inspection and was in the process of reviewing documentation. Three people’s files were looked at in depth, they were found to vary in the quality of care planning. One person required positional changes, however neither day or night staff recorded that this occurred. A pressure cushion was not available for use whilst sitting in a chair. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 12 In some cases, risk assessments were not completed in full and did not show how many carers were required for moving and handling. Another case file assessment indicated that one person had sensory impairment, which was not recorded on care planning. Staff at interview were also unaware of this situation, which may impact on the person’s quality of life in the home. A number of people had sustained falls. No clear strategy was in place for reducing this risk to residents. The falls prevention nurse should be contacted for advice on the prevention and management of falls within the home. Only one staff had received training in falls prevention. Professional visits were recorded and there was evidence of wheelchairs being obtained for people who needed them. The manager said she had arranged for the occupational therapist to visit on 13th September 2007 to assess what equipment was needed. During interviews with people it was noted that there were issues regarding personal care. One person’s eyes needed cleaning on a regular basis, this was not recorded on care plans or daily notes. People’s hair and nails needed attention. One person had dried food on their shoes; others had food on their hands or round their mouth. People confirmed that they had visits from the podiatrist. One person said, ‘the podiatrist comes about every nine weeks.’ Another said, ‘I have a choice of a bath or a shower.’ Also, ‘staff respect my privacy when delivering personal care.’ Interviews with staff and examination of training records highlighted that additional staff training is required in falls prevention, moving and handling and dementia care. The manager said that they were aware of these issues and had contacted Oldham Social Services’ training department to arrange training in line with people’s needs. Comments received from questionnaires included: ‘I have always been satisfied with the people who look after my wife’, ‘All the staff are extremely helpful.’ Also, ‘Staff keep me informed of any doctor’s visits.’ Another questionnaire said, ‘If you ask for something, nothing gets done right away because of problems in change of management and sometimes staff shortages.’ Sit-on scales were available to ensure everyone’s weight could be monitored. Records of weight gain and loss were maintained intermittently. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 13 The policies and procedures regarding medication were poor and did not provide enough information to help staff administer medication safely to residents. The room where medicines were stored was locked, however the medicines within the room were not locked away. During the inspection it was observed that a number of staff who did not have medication training had access to the room. It was also seen that the code for the safe in which the controlled drugs were stored was prominently displayed. Medicines were not stored securely in the home. The standard of record keeping surrounding all aspects of medicines handling was very poor. The records did not accurately show how much medication was kept in the home for each person; also, the records did not show that medication was being administered as prescribed by the doctor. When a sample of the Medication Administration Record sheets (MAR’s) were looked at, together with the medicines in the home, it was seen that some medicines which had been recorded as administered had not been given, because the medication was still in the blister pack and other medicines which had not been signed for as given, may have been administered because the tablets were not in the blister packs or accounted for in any other way. On the day of inspection the new monthly medication cycle had just begun. Staff had failed to transfer vital information from the previous month’s MAR’s to the new MAR’s and so people missed doses of their currently prescribed medication. The medication which was not given to people included antibiotic tablets, creams and anti-depressants. It was of serious concern that people’s health and well-being was potentially placed at risk because doses of vital medication were not given as prescribed. An Immediate Requirement Notice was issued at the end of the inspection to ensure that all currently prescribed medication was recorded on the MAR’s and that clear and accurate records were made when the medicines were administered. There were further serious concerns that residents’ health and well being could be at risk because sometimes medication was unable to be administered, either because it had run out or it had not been ordered at all. It was also of serious concern that staff were unaware of exactly what medication was currently prescribed for each resident and an Immediate Requirement Notice was issued at the end of the inspection to ensure that this information was obtained from the doctors. Staff were also unaware of how to administer some medicines, which either had limited directions printed on the label or those medicines, which had special instructions on how to administer the medicines. People’s health was put at risk due to the lack of knowledge. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 14 There was future cause for concern that people’s health could be at risk because, on some nights, people could not be given any medication they might need, such as analgesia and sprays for angina, because there were no staff on duty who are competent to administer medication safely. The manager did not have a system of auditing medication or checking how medication was being handled and administered, to make sure people’s health is not at risk. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 15 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 People would benefit from an appropriate range of activities and a review of staff routines in the home to ensure their needs are being met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Four-weekly menu planning is in place. On the day of the inspection, it was noted that the cook went round to people to inform them what was for lunch and what choices were available to them. A recent change to meal times has been a move of the main meal of the day from lunch to tea-time. The manager said this was discussed with people in the home who agreed with the change. The reason for this being that a number of people have breakfast later in the day if they choose to get up later and most people were not ready for a large lunch at 12.30. However a hot choice of meal is also offered at lunchtime. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 16 People in the home said, ‘Food is good here.’ Other comments included, ‘I can go to bed and get up when I want.’ The inspector dined with people in the home and found that standards could be improved. Placemats and cloths were dirty and needed replacement. Tea was poured out for people prior to the lunch, with many people having been taken to the table over half an hour before receiving their meal, at which time tea had either been drunk or had gone cold. One person said, ‘It is not fit to drink by the time we get our meal.’ A number of people required assistance with meals. At one time only one member of staff was available to assist six people. Some of these people would have had an opportunity to eat their meals unaided or with prompts, had sufficient thought been given to the height of the table and the positioning of food. At the end of the meal one person was left for half an hour still trying to eat their lunch. A review of staff routines and practices needs to take place, including attention to people’s hygiene before returning back to the lounge areas, as mentioned previously in this report. [See standard health and personal care]. A number of people required attention to their hair and nails. The manager said the hairdresser had recently left and they were actively recruiting a replacement. Activities were limited; one person said, ‘I fill in my time just watching television, I would join in activities if there were any.’ Another person said, ‘the clock is broke now and we don’t know what time it is.’ The new manager said she was aware of some of these issues and had ordered a professional to provide entertainment for Halloween night. Three people spoken to said they manage their own finances. There was evidence in record keeping that people’s preferences; likes and dislikes are discussed on admission. Relatives were made welcome throughout the day. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is adequate Any concerns or complaints are dealt with appropriately, however the lack of formal training in the protection of vulnerable adults may pose a risk to people living in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three different complaints procedures were on various files. These should be reviewed, with timescales for action being standardised so has not to cause confusion. The manager had completed the Annual Quality Assurance Assessment required by the CSCI from which the following information was obtained. Four complaints had been received since the last inspection, which were in relation to personal care and financial records. The previous manager had investigated these and outcomes were recorded to the satisfaction of the complainants. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 18 One person said “I would not have a problem complaining to the manager if I were not happy”. Another said, “If I were not happy I would tell someone but they always look after me”. There had been one incident between two people living in the home which had been referred to the adult protection team to investigate. The CSCI was satisfied that appropriate action had been taken. Twenty-seven care staff are employed, of which six had undertaken training in relation to the protection of vulnerable adults through NVQ training with an additional four receiving training from Oldham Social Services’ training dept. At interview, staff demonstrated knowledge of how abuse may present and their responsibilities should they witness such an event. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 19 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. People are provided with a safe and clean environment, and are encouraged to personalise their rooms making them homely. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A tour of the building was undertaken, which included a selection of bedrooms with most having been personalised by the occupants. Overall, the building is clean and tidy and free from odour, although a smell of cigarette smoke is strong in the rear lounge smoking area, which, unfortunately, can be smelt in other areas of the home. Certain chairs would benefit from cleaning or replacement. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 20 An appropriate range of bathing aids and toilet facilities were present. A range of aids and adaptations were available to assist people with restricted mobility. As mentioned preciously in this report (Standards 8), the manager had made arrangements for an occupational therapist to visit in order to assess the need for additional equipment. There was evidence of maintenance and refurbishment having been carried out. There still remained a number of environmental issues, for example, some failed double-glazing units. The manager said refurbishment was ongoing and there were plans to provide some new chairs for the rear lounge. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 21 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. Recruitment procedures were not robust enough to provide protection for people in the home. The numbers of care staff were sufficient, however the lack of specified routines, staff communication and accountability may lead to people’s needs not being met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: At the time of inspection, sufficient staff were available to meet the needs of people in the home. There are 12 female and eight male staff, which reflect the client group. Women in the home said they had a choice of female worker if they preferred. Examination of the duty rota showed that the deployment of staff needed to be reviewed to ensure that sufficient staff were available throughout the day. Deployment in relation to staff routines, work allocation, accountability and communication also need to be addressed to ensure staff are aware of their duties and responsibilities, ensuring the care needs of people in the home are met. (See Standards 7, 8, 9 and 15). Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 22 One questionnaire said “There has recently been some problems due to lack of staff, but they do address this when it happens.” There was evidence that some staff training had taken place and that the new manager was working in partnership with Oldham Social Services’ training department. Training was needed in the protection of vulnerable adults and conditions associated with old age, for example, stroke awareness, Parkinson’s disease and dementia care. The number of staff who are trained to NVQ level 2 was 30 ; this needs to be increased to 50 . The manager said a number of staff were to enrol for NVQ training. The manager also stated they were a trained moving and handling facilitator, which would mean new staff would receive training in moving and handling on commencing employment. A selection of staff files were scrutinised in connection with recruitment and vetting procedures. In one instance, a person had worked in the home a year previously. In these instances, a new Criminal Record Bureau check must be applied for and references sought. The manger said they had applied for a new CRB, however a POVA First check had not been undertaken in the interim period. On two other files, CRB checks were dated one month after staff had commenced employment. There was no evidence that POVA checks had been carried out. Staff interviewed had a basic awareness of people’s needs. The lack of time to access care plans and assessments may lead to staff having insufficient knowledge of peoples needs. (See standards 7 and 8). There was evidence that staff undertake a basic induction, which then moves onto Skills for Care induction standards. One relative questionnaire said, “I find staff to be helpful and caring”. Also, relatives felt that communication was good between staff and themselves. People in the home said staff were nice to them; one person said “They help me to shave and are very nice”. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 23 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, 36 and 38 Quality in this outcome area is adequate. A sustained period of management needs to be maintained in order to address adult protection issues, quality monitoring, care practices and recording systems in order to ensure the health and safety of people is not at risk. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The new manager had only been in post approximately eight weeks at the time of this inspection and has not yet submitted an application to register with the CSCI, which must now be given priority. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 24 This is the manager’s first experience of management in a residential setting, although they have previous experience in management, working with people with age related diseases and staff training. They hold NVQ level 3 in care practices and have recently completed NVQ level 4 and are waiting verification from the appropriate examining body. They are also a trained moving and handling facilitator. The manger had completed the Annual Quality Assurance Assessment required by the CSCI. Although this required more information on assessments, care practices and development, they were able to demonstrate an awareness of areas that needed improvements, for example, care planning and how these would be addressed. Particular attention needs to be paid to addressing areas identified in this report in relation to recruitment, the delivery of personal care, staff training and accountability; also, improving recording and medication systems. Staff had not been receiving supervision; implementing this would be a means of identifying training needs. Conflicting views were obtained through questionnaires, for example, one person said, “You can ask for things but nothing ever gets done” while another said “Stoneleigh House has been through a very unsettled period this year, I felt the care fell short of my expectations during this period, however, since the new full time manageress took over, new staff have been arriving and the home has improved greatly; hope it keeps that way.” Also, “I feel that staff training has improved recently, but there were problems before the recent changes.” Quality assurance systems need to be developed to include the views of people in the home, relatives and professionals. There was evidence that the manger had undertaken meetings with people in the home and staff in order to gain their views. Whilst there was clear evidence that the owner was a frequent visitor to the home, there was no documentary evidence of a specific monitoring visit report on the running of the home. A selection of records relating to money held by Stoneleigh House on behalf of people in the home was scrutinised. These stipulated incomings and outgoings, with receipts being retained for proof of purchase. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 25 The Annual Quality Assurance Assessment completed by the manager stated that service checks had been carried out on the lift, fire detection and electrical equipment. The manager reported that other equipment checks had taken place but documentation for these was situated in the main office of the company. Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 26 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 27 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. Risk assessments must be completed which provide instruction to staff on how many staff are required to carry out moving and handling, so that residents are moved safely. The manager must ensure that a strategy is in place for the prevention and management of accidents in the home which promotes residents living in a safe environment. Appropriate pressure relieving equipment must be available for people to ensure that pressure relief to skin is provided as appropriate. The medication policies and procedures must be reviewed and updated, so that clear information is provided for staff and to ensure residents are not placed at risk. DS0000005521.V346972.R01.S.doc Timescale for action 31/10/07 2 OP8 15 30/09/07 3 OP9 13(2) 14/10/07 Stoneleigh House Version 5.2 Page 28 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. 4 Standard OP9 Regulation 13(2) Requirement All medication must be stored safely and securely at all times to make sure that residents’ health is not at risk. Medication must be administered to residents exactly as prescribed by the doctor at all times, to ensure their health and well being are not at risk. Records regarding medication must be clear and accurate at all times in order to ensure that residents are administered the correct medication. At all times there must be staff on duty who are suitably qualified, competent and experienced in the administration of medication to make sure that residents’ health is not at risk. Residents must be safely given their medicines; staff must have the knowledge to administer them safely. Staff must ensure that people living in the home have their personal hygiene needs attended to better and more consistently, thereby upholding residents’ dignity. Timescale for action 14/10/07 5 OP9 13(2) 14/10/07 6 OP9 17(1) 03/09/07 7 OP9 18(1) 03/09/07 8 OP10 18 30/09/07 Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 29 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. 9 Standard OP29 Regulation 19 Requirement The registered person must ensure that all checks on new staff are undertaken so that only suitable people are employed to work in the care home. (Timescale of 01/07/06 not met) Timescale for action 30/09/07 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 *RCN OP1 OP9 Good Practice Recommendations An application to register the manager with the CSCI must be submitted, as stated in the Care standards Act 2000 Section 11. Ensure that the statement of purpose and service user guide state where the last inspection report can be found in the home. A system to audit medication and to assess the quality of medication handling should be established and maintained by the manager, to ensure that the quality of medication handling is assured and residents’ health is not at risk. Provide a range of activities for people in the home and maintain records of any activities undertaken. 4 OP12 Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 5 Refer to Standard OP15 Good Practice Recommendations Review staff routines over the lunchtime period to ensure hot food is served and people are not taken to the table too early, with their personal hygiene being attended to before returning to the lounge. The complaints procedure should be standardised so all people in the home and their relatives receive the same guidance on how to make a complaint. The manager should continue to consult with Oldham Social Services’ training department to ensure all staff receive training in the protection of vulnerable adults. A refurbishment plan should be completed for any outstanding issues, for example, failed double-glazing and replacement chairs, with timescales for completion. Ensure staff progress on the NVQ training is monitored to maintain at least a minimum 50 of care staff with NVQ II or above. The registered person should ensure that a report is produced following a Quality Monitoring and Quality Audit process, which takes into account the views of service users, relatives and professionals. 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. Staff routines should be revised to ensure people’s personal hygiene is maintained to a good standard. 6 7 8 9 10 OP16 OP18 OP26 OP28 OP28 11 OP28 12 13 OP36 OP36 Stoneleigh House DS0000005521.V346972.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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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