Inspection on 04/04/07 for Stoneleigh House

This inspection was carried out on 4th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stoneleigh House 18/06/08

Stoneleigh House 21/03/06

Stoneleigh House 16/11/05

Stoneleigh House 10/03/05

Stoneleigh House 17/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stoneleigh House 2 Rowlands Hill Wimborne Dorset BH21 1AN Lead Inspector Debra Jones Unannounced Inspection 4th April 2007 10:00 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 DS0000026875.V335402.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 DS0000026875.V335402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoneleigh House Address 2 Rowlands Hill Wimborne Dorset BH21 1AN 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) 01202 884908 01202 818349 helen@stoneleighhouse.com Ms Helen Vivienne Edbrooke Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 2006 Brief Description of the Service: Stoneleigh House is a substantial older style property close to the centre of the market town of Wimborne; which provides all local amenities including high street shops, post office, banks and building societies as well as GP surgeries, a cottage hospital and various places of worship. Placed in well-maintained, pleasant gardens, the house comprises three floors of accommodation. The top floor provides private accommodation for the owners whilst the ground and first floor are for resident use. There are eight single and two double rooms, all with en-suite facilities. Registered for 12, the home maintains occupancy at 10 as double rooms are used for single occupancy. Communal space includes a pleasant lounge and dining room. There are family rooms, used mainly by Mrs Edbrooke and her family on the ground floor at the rear of the home although staff and residents are not excluded from these areas. The kitchen and laundry area are sited on the ground floor and there are sufficient communal bathing and toilet facilities throughout the home for the number of residents. Current weekly fees range between £350 and £450. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place on Wednesday 4th April and Thursday 5th April 2007. The last inspection took place in March 2006. The inspection was undertaken as part of the normal inspection process legally required in accordance with the Care Standards Act 2000. The home was assessed against the Care Home Regulations and National Minimum standards for older people. Information was gathered through general observation, discussion with Ms Edbrooke and staff on duty. A tour of the premises and examination of the records kept in the home provided further information. There were 10 residents accommodated in the home. Three were spoken to during the course of the inspection in the privacy of their rooms. Comments at the visit and on comment cards sent to the Commission since the last inspection visit included the following:‘I’m very happy here, you can’t fault it!’ (a resident) ‘Helen (Edbrooke) is so good to us.’ (another resident) ‘We are fortunate that this is a small unit.’ (another resident) ‘I’m glad to be here.’ (another resident) ‘Stoneleigh House is a very nice home to be in. I am well cared for and I feel very happy here.’ (another resident) ‘Stoneleigh House is a first class residential home. I have been very happy with the care and respect which my mother has received in the 18 months she has been there. I have every confidence in the way Helen Edbrooke runs the home.’ (a relative) ‘Very satisfied with the level of care, dietary needs/ provision and social welfare provided. A family run business. A gem of a care home and not large and impersonal.’ (another relative) ‘As good a care home as you would ever wish for!’ (a GP) ‘This is fantastic home – one of the best!’ (another GP) What the service does well: Stoneleigh House has a relaxed, homely and friendly atmosphere. The home is comfortable and welcoming. The home provides contracts for residents that are clear about their rights. Before residents move to the home they are welcome to visit, look around and discuss the service on offer, as are their relatives or representatives. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 6 All residents have care plans based on a range of assessments that set out how the residents’ care is to be delivered by staff. Residents at the home have access to, and are well supported by, a range of community health professionals. Residents say that they have their privacy and dignity respected by all at the home. Their visitors are always made to feel welcome. Residents talk of the ‘free and easy’ atmosphere in the home and choose how they spend their days. Some social activities are on offer and are appreciated by residents, particularly the weekly outing. The standard of food is good. All residents spoken with praised the food, which is wholesome, nutritious and plentiful. There is a complaints system in place and staff are trained in adult protection awareness. The home is well maintained and residents are able to personalise their bedrooms as they wish. The home offers consistency of care to residents through their stable staff group and owners who live on the premises. Care staff are well trained to do their jobs and residents say they are well cared for. Stoneleigh House is managed by Helen Edbrooke who has the experience and qualifications to do this. The home is not involved in the personal finances of residents. What has improved since the last inspection? What they could do better: Pre admission assessments need to be carried out for all prospective residents interested in moving to Stoneleigh House. Once the home has established if they can meet their needs this must be confirmed to the resident in writing. Residents at the home are able to be involved in drawing up and reviewing their assessments and care plans and so should be to ensure that both parties are happy with their content and what care staff are to deliver. Any written records relating to residents, including care plans, should be written respectfully and non judgementally. In order to support residents health and well being medication must be properly administered. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 7 Good practice guidance needs to be followed in respect of medication administration and medication records must be a true record of what medicines residents take. All medicines in the home must be stored appropriately. Staff records must include the documentation required by law to evidence that only suitable people are working at the home. The home needs to draw up an annual development plan that incorporates a quality assurance / monitoring system to evidence the ways in which the home achieves the aims and objectives set out in the statement of purpose and service user guide. The home must regularly review their risk assessment of radiators and pipe work and take appropriate action to ensure the safety of all residents and visitors. It is further suggested that the staff induction programme is reviewed to ensure that it is in line with the Skills for Care industry standard. 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 DS0000026875.V335402.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 DS0000026875.V335402.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): 2, 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service get the information they need to know what they are entitled to expect. Prospective residents and their representatives are encouraged to visit the home prior to moving there and prospective residents can stay for a trial period allowing them time to decide if they wish to live at the home. Not all residents living at the home had personalised pre admission assessments carried out to ensure that their diverse needs are identified and planned for before they move to the home. They are not all reassured in writing that their needs can be met. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 10 EVIDENCE: At previous inspections care records for recently accommodated residents evidenced that Ms Edbrooke undertook pre admission assessments to establish each prospective resident’s care needs prior to admission. The details obtained included all recommended topics and considerable information about social activities, personal interests and independence. Since the last inspection visit only one new resident had been admitted who had moved from another part of the country, their family had visited the home and had discussed the prospective resident’s needs with Ms Edbrooke prior to them moving to Stoneleigh House. The resident talked of how he had come to the home on a trial basis and had decided to stay for the time being ‘it was better than I expected and they supported me very well to settle in.’ For this resident there was no evidence of a written pre admission assessment and the home had not confirmed in writing that the home could meet his needs. Contracts are issued to all residents and these include all the information required by law. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not involved in the drawing up of their care plans despite being capable of doing and so cannot be sure that their views on their health and personal care needs are being fully taken into account. Professionals based in the community meet the health care needs of residents. At times poorly completed medication records and unsafe administration systems mean that residents may not be given their medicine or may being given the wrong medicines. This puts service users at risk of harm. Residents confirmed their privacy is protected and that their known wishes are respected. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each resident at the home has a care plan based on a range of assessments. The care plans and associated records for four residents were examined. Assessments and care plans are regularly updated and are there to provide guidance for staff to determine how identified needs should be met. Care related risks are included in the plan. Examples of poor use of language in assessments, care plans and daily notes were brought to the attention of Ms Edbrooke and these need to be urgently reviewed, along with any other documentation and notices around the home etc to ensure that all written information about residents is recorded in a respectful and non judgmental way. Residents spoken with at the visit were not aware of their care plans and there was no evidence to show that residents had been involved in the construction of these care plans or in their reviews. Residents at the home are very able and would be capable of doing this. Residents talked of the assistance and support they got from the staff, enabling them to maintain their own independence and stepping in to assist them with parts of tasks they had difficulty with. ‘We are very well cared for.’ (a resident). Daily care notes and records demonstrated that other care professionals are contacted for guidance and assistance when needed. One resident had a visit from a district nurse during the inspection visit and another talked of how they had been to the local GP surgery that morning. Residents said that they had confidence in the way the home looked after their medication for them. The home has a written policy and procedure regarding the receipt, recording, storage, handling, administering and disposal of medicines. A local pharmacist supplies the medicines using a monitored dosage system (MDS) and provides computer generated Medication Administration Record (MAR) sheets. Any homely remedies used are detailed on the reverse of the MAR sheets. All medication received into the home is signed for and dated. A set of sample signatures (initials) were seen as per good practice, so it is clear who has signed the records. In most cases medication records tallied with the medicines on the premises but some errors were noted and brought to the attention of Ms Edbrooke, some medicines had not been signed as administered, although the medicines were not in the MDS so it is assumed that they had been taken by the resident. In another case a medicine that should only be administered once a week was noted on the MAR sheet as having been administered 5 times in a Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 13 week. Again the medicines on the premises appeared to be right with what should have been administered. Where handwritten entries / changes had been made to the printed MAR sheets these were not signed or countersigned by the person making the changes. It was noted that the home is double dispensing medication i.e. transferring medication from the original pharmacy supplied and labelled containers into other containers for later administration by other members of the home’s staff. Medication is taken from the containers and put in pots in the evening to be administered in the morning with breakfast. This is an outdated and unsafe practice and is not in line with the practice as described in “The Administration and Control of Medicines in Care Homes and Children’s Services”, produced by The Royal Pharmaceutical Society of Great Britain (June 2003). This states at paragraph 6.2.3: “Medication should never be removed from the original container in which a pharmacist or dispensing doctor supplied it until the time of administration”. and “Medication should never be secondary dispensed for someone else to administer to the service user at later time or date”. This medication administration practice is also described as frequently associated with medication errors in a report by The Department of Health, “Building a Safer NHS for Patients, Improving Medication Safety” (January 2004). Also staff are signing to say that the medicine has been administered at the point where they are taking it out of the packaging rather than as they should be at the point when the resident takes the medication. Some residents are looking after their own medicines and residents sign a declaration confirming their capacity and willingness to self medicate. ‘They only let you handle it if you are capable of doing it.’ (a resident). Whilst it is stated in the assessment/ care plan for each of these residents that this is the agreement, the home is not recording an assessment of the persons ability to look after their own medication that has lead them to agree this with the resident. Residents also sign to say that they will keep their medication safely locked away. In practice this is not always the case. Some medicine is kept in the main fridge. The fridge temperature is appropriately checked to ensure that the medicine does not get too cold or too warm. The medication is kept in a plastic box, which is not lockable. At the visit not all the medicine was in the box. All residents spoken with said that their privacy is respected and that they were treated with dignity. People talked of how staff always knocked on doors and called them by the names they liked to be called. One talked of how staff Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 14 helped her with bathing ensuring her privacy and comfort during the task and of how her modesty was protected. Stoneleigh House DS0000026875.V335402.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents confirmed that the social care arrangements in the home meet their expectations. Residents also benefit from being encouraged to have contact with relatives, friends and the local community and in determining themselves how they spend their days. Meals and mealtimes are an enjoyable, social occasion for residents. EVIDENCE: Residents at the home continue to retain a high degree of independence, choose the activities they wish to participate in and decide how they like to spend their days. Residents talked of the enjoyable weekly outings that Ms Edbrooke takes them on in a hired minibus. They also talked with appreciation about the additional staff member on duty on Tuesday afternoons who does personal shopping for Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 16 residents and is available for other types of individual assistance thereby promoting independence and autonomy. ‘She comes round to all of us, inevitably I need something; lovely really.’ Residents said they went out for walks and to the shops and others talked of how they liked to spend their time. ‘I have a newspaper daily, it keeps you in touch.’ (a resident). Residents see mealtimes and outings as particularly sociable times and described themselves as a group that gets on well. Residents said that they like to spend time reading in their rooms, doing puzzles, watching TV and listening to the radio. One talked of how they and another resident enjoyed sitting in the summerhouse in the garden in the warmer weather. Residents spoken with confirmed that visitors are welcome at the home at any time this. ‘Visitors come any time they like, are always made to feel welcome, they always bring them drinks. They can stay to lunch or have sandwiches in the evening. They’d be given a meal if they have come a distance.’ (a resident) One resident had been out visiting their family the previous evening. Residents spoke of the choices they made living at the home ‘there’s certainly choice here!’ and it’s very ‘free and easy.’ ‘Not at all institutional.’ All residents spoken with praised the food, saying it was varied, well presented and of how there was choice. ‘It’s very good.’ (a resident). ‘Excellent food.’ ‘always fish on Fridays and the vegetable soup they make is very good.’ They also talked of how there were ample portions provided and they were always asked if they wanted more. Residents said that when they first moved to the home they were asked about their dietary needs and preferences and that these were respected. One resident talked of how they had been trying to put on weight since moving into the home and of how they were enjoying succeeding in this. On the first day of the visit lunch was savoury minced beef, tomato and onion, served with cauliflower, carrots and potatoes. Strudel and custard was for dessert. On the second day it was roast duck, roast potatoes and vegetables followed by a homemade custard tart. There is always a hot choice at supper. Ms Edbrooke or the care staff on duty undertake catering duties. Some staff are about to go on food hygiene refresher training. Stoneleigh House DS0000026875.V335402.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Formal complaints and adult protection procedures are in place supporting residents to feel safe and listened to. EVIDENCE: The home has a complaints procedure and a complaints form is readily available in the lounge. The Commission has received no complaints regarding Stoneleigh House over the past year and no formal complaints have been received in the home. Residents said that they would feel comfortable raising any issues of concern they had with staff. The home’s adult protection policy has been shared with staff. Ms Edbrooke and staff spoken with at the visit have undertaken the local training concerned with ‘No Secrets’. More training in this area is currently being advertised at the home. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained, providing an attractive and comfortable environment for the residents who choose to live there. EVIDENCE: Stoneleigh House is a substantial property set back off a main road in Wimborne near to the range of town amenities including shops, the post office, churches and pubs. Bedrooms are on the ground and first floors. Access to the majority of bedrooms is via a staircase to the first floor. Residents who do not reside on the ground floor must have sufficient mobility to manage the stairs safely. Bedrooms are personalised by residents as it suits them. All bedrooms have en suite facilities. ‘I have a handy wash basin and toilet in my room.’ (a resident) Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 19 Communal areas are comfortably furnished, clean and free from unpleasant odours. Residents said that their rooms were cleaned regularly. ‘They keep the place very clean.’ (a resident) The laundry room in being redecorated and the flooring improved. Liquid soap was available and a paper towel dispenser is to be put up. Residents said that they were happy with the laundry arrangements. ‘They wash iron and bring back my laundry quickly.’ (a resident) Stoneleigh House is homely and well maintained with appropriate facilities provided for the comfort of residents. Routine maintenance is undertaken as required and rooms refurbished as they become vacant. Planned maintenance schedules are followed in respect of fire equipment and electrical installation/equipment. The home complies with the requirements of the local fire authority. The home’s garden is sheltered and well maintained with lawn areas, mature trees and shrubs and attractive flower borders. A summer- house with comfortable seating is situated in the back garden and garden furniture is available. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is staffed by suitable numbers of appropriately trained staff. However staff records are not currently demonstrating that all documents relating to staff, in order to safeguard the welfare of residents living in the home, and being kept. EVIDENCE: The home’s staff rota demonstrates that there are at least two staff on duty in the home from 8am to 8pm every day. Ms Edbrooke and her husband sleep-in and are on call throughout the night should anyone call for assistance: the family live in private accommodation within the home. The home employs a total of 9 staff, their duties include domestic tasks, catering and associated tasks and social care in additional to personal care provision. As the residents who live in the home have low dependency care needs and undertake much of their own personal care the staffing arrangements are satisfactory. Residents said that staff were very kind,’ they do anything they can to help us.’ ‘The staff are wonderful.’ ‘If they can do it, they do.’ Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 21 ‘The staff are all very nice. They are always ready to have a chat when I want to see them.’ (another resident) Ms Edbrooke reported that the staff team is stable and that no new staff had been employed since the previous inspection. The home were reminded of the need for them to keep all the required documentation in respect of their staff e.g. proof of identity, proof of CRBs (obtained in the name of the home for staff employed after the introduction of the Protection of Vulnerable Adults list in July 2004.) Staff talked of the training that they had at the home and of how they felt that it equipped them to do their jobs well. Since the last inspection staff have had training in infection control, adult protection awareness, induction and dealing with challenging behaviour. First aid training is planned and 4 staff are doing food hygiene updates. Staff undergo a comprehensive induction. Ms Edbrooke is encouraged to check that this induction is in line with the latest Skills for Care induction programme, which is now considered to be the industry standard. Mrs Edbrooke reported that over 50 of the care staff hold a national vocational qualification in care at level 2 or equivalent. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management and working practices generally ensure that the health, safety and welfare of residents and staff are promoted and protected. The home does not have a formal quality assurance system to show that Stoneleigh House is run in the best interests of residents. EVIDENCE: Ms Edbrooke has managed and run the home since 1996: she is a qualified nurse and remains ‘live’ on the National Midwifery Council register. She has completed the Registered Managers award. Her husband assists with management tasks. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 23 The home has not established a quality assurance system or prepared annual development plans that would regularly demonstrate how the home is meeting it’s stated aims and objectives. The change to the Care Home Regulations in 2006 regarding quality of care was brought to the home’s attention. Residents control their own money wherever possible. In the event they are unable to family or solicitors take control of their finances. The home does not hold any personal money or valuables belonging to residents. Staff keep records of accidents to residents. These were generally well completed and cross-referenced with daily notes on care files. Ms Edbrooke does not formally review and analyse accidents and falls in the home. Ms Edbrooke said that all staff were up to date with fire training and staff confirmed that they had had fire training in recent weeks. Residents said that they heard the regular tests of the fire bells. The home has completed a comprehensive fire risk assessment as required by law. In respect of general matters of health, safety and risk the home are asked to return to their radiator and pipe work risk assessment and ensure that it is up to date and take action appropriately to minimise any risks. E.g. in the dining room there is an exposed radiator directly next to where residents sit and eat which was hot to the touch at the inspection visit. Residents have access to the emergency call bell system throughout the home. ‘Staff come quickly when you ring the bell.’ (a resident) ‘It’s super, if you ring the bell they come.’ (another resident) ‘If I want something in the middle of the night I press the bell and they come.’ (another resident) The home keeps maintenance records and certificates issued by the various companies completing the servicing /inspections. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 24 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 3 1 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 Requirement The registered person must only provide accommodation to a resident after a needs assessment has been carried out. The registered person must confirm in writing that having regard to their pre admission assessment the care home is able to meet their health and welfare needs. The written care plan must be • prepared in consultation with the resident, • the plan must be made available to the resident, • the home must consult the resident over reviews of the plan and • notify them of any revision. • The practice of double dispensing medication must stop. • Medication records must accurately reflect the medication administered. • Handwritten entries to medication records must DS0000026875.V335402.R01.S.doc Timescale for action 30/06/07 2. OP4 14 30/06/07 3. OP7 15 30/06/07 4. OP9 13 30/04/07 Stoneleigh House Version 5.2 Page 26 5. OP29 19 6. OP33 24 7. OP38 13 be signed and countersigned by competent people. • Where residents are looking after their own medication there must be an assessment made by the home as to their ability to do this. • All medication in the home must be stored safely and appropriately. Evidence must be kept on file that suitable recruitment procedures have been followed i.e. all documentation listed in schedule 4 relating to staff must be held and be available for inspection. The registered person must establish and maintain a system for evaluating the quality of the services provided at the care home. This system must provide for consultation with residents and their representatives. The registered person shall ensure that all parts of the home are free from hazards and unnecessary risks to the health or safety of residents are identified and so far as possible eliminated i.e. carry out and act upon thorough risk assessments of radiators and pipe work. 30/04/07 30/06/07 30/06/07 Stoneleigh House DS0000026875.V335402.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. Refer to Standard OP7 Good Practice Recommendations Any documentation relating to residents should be written respectfully and using non-judgmental language. Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stoneleigh House DS0000026875.V335402.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!