Inspection on 09/06/05 for Stoneleigh House

This inspection was carried out on 9th June 2005.

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

The inspector 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 17/06/09

Stoneleigh House 23/01/08

Stoneleigh House 03/09/07

Stoneleigh House 28/07/07

Stoneleigh House 18/05/06

Stoneleigh House 13/10/05

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 Cooper Street Springhead Oldham OL4 4QS Lead Inspector Sandra Bennett Announced 9 June 2005, 09:00 th 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 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 F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stoneleigh House Address Cooper Street Springhead Oldham OL4 4QS 0161 624 5983 0161 678 2158 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Masterpalm Properties Limited Joan Mills Care Home 31 Category(ies) of DE(E) Dementia 65 - 8 registration, with number OP Old Age - 23 of places Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Service user to include up to 23 OP up to 8 DE(E) Date of last inspection 24th November 2005 Brief Description of the Service: Stoneleigh House is a detatched property in a semi-rural location. It is situated close to public transport and local amenities. To access the property service users have to manage a small incline from the main road. The outside of the property is well maintained with landscaped gardens and views over the local area. Accommodation is provided in 27 single rooms, of which 26 have an ensuite facility. Of the twenty six rooms two share an adjoining ensuite. There are two shared rooms, both of which have ensuite. Communal facilities include three large lounges one of which is an allocated smoking area and a large dining room. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This scheduled inspection took place on 9th June 2005. Time was spent talking to eight service users, two relatives and three staff. The care for four service users were looked at in detail, looking at their experience in the home from the time of their admission to the present day. Records of care were examined along with staff duty rotas, personnel files, financial records and medication records. Four complaints regarding care delivery, staffing levels and laundry problems were also investigated during the inspection. Six service users questionnaires were returned, four of which commented on the lack of social activities, but were satisfied with the care delivery. Two relatives questionnaires were received, one stated general satisfaction, while the other reported that they were not kept informed regarding important matters affecting their relative. They reported that they were unaware of the homes complaints procedure and they felt there was not sufficient staff on duty. They also stated that they were satisfied with the overall care provided. At the end of this inspection the provider was given immediate feedback on many issues raised in this report and the action required to address issues raised. What the service does well: What has improved since the last inspection? There have been some improvements to the environment in the home, i.e. bedrooms have been decorated and some carpets replaced. Most radiators have been provided with guards, with the remainder included in the refurbishment plan. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 6 The streamlining of care planning had begun with those completed fully, providing sufficient information to staff to be able to deliver care effectively. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home encourages families to visit prior to admission and obtains a professional assessment of the service users needs. There was a lack of information available to service users for them to make an informed choice about living in the home. EVIDENCE: A case file of a newly admitted service user was examined and found to include a summary of their assessed needs from a health care professional. Interviews with the service users and their relative highlighted that no information regarding what the service offers had been provided. However, they did confirm that they were encouraged to visit the home and meet with other service users and staff. The family was informed by the home that a top up fee was payable but, unfortunately no explanation was given as to what additional service would be provided for the additional fee. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 9 This information should be included in the homes statement of purpose and service user guide and given to service users and families prior to their admission enabling them to make an informed choice. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The health care needs of service users were not consistently recorded which may pose a risk to service users. Procedures for the storage, recording and handling of medication needed to be reviewed. The privacy of service users was compromised due to files not being stored securely. EVIDENCE: There was evidence of good care planning from service users assessments. The recording system was in the process of upgrading to give a streamlined and comprehensive approach. As a result of this process those files completed had full details of healthcare needs and professional visits, all other files not completed must be brought into line in order to provide a comprehensive system. Omissions were noted on certain files in relation to reviews of care plans, and dates and signatures of persons completing the care plans, also specific health care needs regarding oral hygiene and nutritional screening. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 11 Accidents sustained by service users had been fully recorded and followed through into daily reports and care planning. In one instance a service user had been provided with bed rails without evidence of consultation with health professionals. Examination of care plans, interviews with staff and service users found there to be insufficient moving and handling equipment to meet the needs of service users. Moving and Handling training had been provided. However the high turnover of staff in the home reduced the effectiveness. This situation must be constantly kept under review to ensure the health care needs of service users are met. Examination of medication policies and procedures found that items of medication were being stored in the medication fridge, which should have not been. The homely remedies policy did not give sufficient detail of what each service would be allowed to take after consultation with their GPs. The recording of controlled drugs had not been completed accurately neither were they stored in a specific cupboard which met the Royal Pharmaceutical Guidelines for care homes. Senior staff had all received training in the administration of medication observed practices on the day of inspection were deemed to be correct. Service user files were retained in an enclosed area of the dining room, allowing easy access for staff. However, this may compromise the privacy of service users due to access from other service users or visitors. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. There was a lack of social activities for service users and the need to take into account their wishes choices regarding their preferred lifestyle in the home. Meal times were well managed. The high turnover in the staff team meant inconsistencies in practices and routines. EVIDENCE: Food served was nutritional and of ample portions. Each lounge has a space for dining providing a more intimate setting for service users. On the morning of the inspection several service users had chosen to have a late breakfast with lunch being a light meal and the evening meal being the main meal of the day. Service users confirmed that they enjoyed the meals in the home. Nine questionnaires were sent to service users four of which reported that activities took place sometimes. However this is when staffing levels allow. Examination of financial records showed outings had taken place in the community to which service users had made a small contribution. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 13 The Commission of Social Care had received several complaints in relation to laundry problems and missing clothing. When this issue was discussed with service users and their relatives they reported that things had greatly improved. However problems still occurred at weekends due to staff shortages. Relatives and service users complained over the high turnover of staff. Discussions with the management team provided evidence that these issues were being addressed. Other complaints relating to service users lifestyle in the home stated that service users had little choice in when they got up in the morning, one service users stated they would like to get up earlier and one who would prefer to stay in bed. Service users confirmed that a church service is held monthly for those wishing to participate. Service users confirmed that visiting was able to take place at any reasonable time and that visitors were made welcome. During interviews with relatives and service users they praised the commitment of staff and their caring attitude towards service users. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Relatives felt their complaints about care were not always listened to. Service users are protected from abuse. EVIDENCE: Examination of service users files found that several versions of the home’s complaints procedure were on files, only one of which was correct. Accurate information must be given to service users on how to make a complaint and the timescales involved. Complaints received had not been fully logged by the home. Those relatives who had complained felt they had not been listened to. Four complaints had been forwarded to the CSCI which related to laundry problems, service user choices in when to rise and go to bed, privacy, moving and handling equipment, care practices, staffing levels and training all of which were investigated and substantiated on investigation. It is acknowledged that the home was aware of some of these issues and had begun to address them. A procedure for responding to allegations of abuse was available for staff reference with staff at interview being aware of how abuse may present and action they would be required to take if witness to such. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The home has continued to make improvements in the environment and has sufficient communal facilities to meet service users needs. Service users rooms were personalised and free from odour. Aids and adaptations are provided in the environment to promote the independence of service users on an individual level. There was a lack communal moving and handling equipment. EVIDENCE: Since the last inspection the home has continued with their refurbishment programme and improvements to the environment. A number of areas still require addressing, some bedrooms were without easy chairs or chairs that required replacing. There was evidence that several carpets had been replaced with others being included in the refurbishment plan alongside the failed double-glazing units. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 16 Many service users had chosen to personalise their rooms providing a homely appearance. One service user had installed a private telephone line in their room. Bedrooms have ensuites, two rooms have an adjoining ensuite, there are additional toilets situated in communal areas. One bathroom is adapted for service users with a disability. The home is well maintained both inside and outside with landscaped gardens and seating areas for service users. It was clean and tidy and free from odours. There is a choice of three lounges, which also provide dining spaces. Service users are assessed for individual aids to promote their independence. There was a lack of moving and handling aids and adaptations. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Staff recruitment, training and induction were not robust enough to provide adequate protection for service users. The lack of ancillary staff over a weekend period compromised safety and hygiene standards in the home. The number of staff who hold NVQ needs to be increased. EVIDENCE: A number of staff had completed NVQ2 training however this still did not meet the required number of 50 . A staff induction was in place, which was not sufficient to instruct staff on care principles and moving and handing techniques. There was a record of individual staff training in place however on examination many were found to be outdated with refresher courses on new techniques now being required. Examination of duty rotas, interviews with staff and service users found that on many occasions there had been staff shortages especially over the weekend period. Due to a shortfall of ancillary staff in care staff had required to undertake cleaning and laundry duties, which resulted in service users needs not being met in some instances. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 18 Staff records showed a high turnover in staff. There were failures in the home’s recruitment procedures in the lack of written references and Criminal Bureau Records Checks. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38. Management practices in the home are poor. There is a lack of formal supervision and guidance for staff in order to ensure consistent care practices. Consultation needs to be increased regarding service users expenditure. The health and safety of service users was not safeguarded by the policies, procedures and record keeping. Quality assurance methods were insufficient to provide opportunities for the families of all service users to offer their views on running the home. EVIDENCE: During approximately eighteen months there has only been a manager in post for eight months who at the time of inspection was absent from the home due to ill health. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 20 Although improvements had begun to take place in care planning and record keeping this had not been sustained. Regular staff supervision had not taken place. Interviews with staff showed there was no system in place for task allocation, although a handover did take place at change of shift to help focus on the care needs of service users. A communication book was available for staff to write the care needs required by service users, this was not always followed through by senior staff due to the lack of management guidance and lack of direction to senior staff. Management practices in the home does not promote accountability for staff and may lead to task being overlooked putting service users at risk. Examination of service users financial records showed the monies held on behalf of service users correlated with the recorded amount. Irregularities in records were found, although the inspector was satisfied there was no misappropriation of any service users funds. There had also been expenditure made on behalf of two service users, where appropriate consultation had not taken place with families or health care professionals of the service users. There was evidence on staff files that appropriate health and safety training alongside infection control had taken place. Families and service users reported that they were consulted on issues relating to the home however this was not on a regular basis. The home has no formal quality assurance system in place to review any aspect of the service it delivers. Although the owners of the home visit Stoneleigh House on a very regular basis, there was no evidence that they reviewed the standards of care delivered to service users. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 2 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 2 2 2 2 2 2 2 Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 22 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 1/37 Regulation 4/5 Requirement The registered person must ensure service users and their representatives are provided with information on the facilities, services, and the reason for any additional charges. The registered person must ensure that a completed care plan is in place which reflects the assessed needs of each service users. The registered person must ensure moving and handling equiptment is provided to meet the assessed needs of all service users. The registered person must ensure the appropriate storage and recording of controlled drugs in line with the Royal Pharmaceutical Guidelines. The homely remedies procedure in the home must be reviewed to include what remedies the service users can take after consultation with their GP. The registered person must ensure that information relating to service users is kept away from public view. Timescale for action 31/9/05 2. 7/37/38 15(1) Immediate 3. 8/22/38 12 Immediate 4. 9/37/38 13 (2) Schedule 3 17 1(a) Immediate 5. 10 12(4) Immediate Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 23 6. 16/37 22(5) 7. 27/38 18(1) 8. 9. 28/30 29 18(1) 19 schedule 2 10. 32 12(1) 11. 33 15(1) 12. 34/35 15(1) 13. 36/38 18(2) The registered person must ensure that the complaint procedure is upgraded to provide service users and their representatives with sufficient information on how to make a complaint. All complaints made to the home must be recorded. The registered person must ensure that sufficient care and ancillary staff are on duty at all times to meet the needs and promote the choices available for all service users. The registered person must ensure the number of staff who hold NVQ2 is increased to 50 . The registered person must ensure that criminal records bureau checks are obtained along with two written references before their employment is confirmed. The registered person must ensure that the management of the home gives a clear sense of direction leadership and guidance to staff to ensure consistancy in care practices. The registered person must ensure that service users and their representatives are consulted on care practices and have the oppotunities to offer their views on running the home. The registered person must ensure that consultation with service users and their representaives takes place prior to any expenditure of service users money. The registered person must ensure that care staff receive supervision at least six times per year. 31/9/05 Immediate 31/12/05 Immediate 30/9/05 30/9/05 Immediate Immediate Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 24 14. 33, 37 26 The registered person must visit the home each month and prepare a written report on the conduct of the home and provide a copy of the report to the commission. 01/09/05 15. 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 12/14 20 8 Good Practice Recommendations The registered person should ensure that consultations take place with service users on their preferred lifestyle in the home reflecting this in care planning. The registered person should continue with the refurbishment plan of the home to ensure standards are maintained. The registered person should ensure that the use of bed rails is recorded on service users care plans and include details of any consultation that has taken place between social and health care professionals. Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 OQD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stoneleigh F54-F04 s5521 Stoneleigh Hse v222444 090605 Stage 4.doc Version 1.30 Page 26 - 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!