Inspection on 11/05/05 for Stoneleigh

This inspection was carried out on 11th May 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 12/07/06

Stoneleigh 23/11/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Stoneleigh 19 Victoria Road Stechford Birmingham B33 8AL Lead Inspector Kath Strong Unannounced 11th May 2005 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 E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stoneleigh Address 19 Victoria Road, Stechford, Birmingham B33 8AL 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) 0121 628 6099 0121 628 6098 Mrs P Sale and Mrs A Smith Mrs P Sale Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number of places Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/01/05 Brief Description of the Service: Stoneleigh is an adapted domestic property located within the resdiedntial area of East Birmingham. The home is situated close to a local railway station and is well sited for public transport links and local road networks. There is sufficient off road parking at the front of the premises to accommodate 2 vehicles. Stoneleigh can provide residential accommodation for 15 older persons. The home has eleven single bedrooms and two shared rooms. Twelve bedrooms are loacted on the two upper floors and a single room is situated on the ground floor. there is a shaft lift ,which enables access to the first floor. The premises include a flat on the upper floor which is currently utilised by staff for sleep-in purposes. Communal space is offered in two lounges, a dining room and a conservatory. There is a secluded sloping rear garden including a paved area where residents can sit during clement weather. The home has a bathroom on each of the upper floors and a spacious assisted shower room is located on the ground floor. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is as a result of the first inspection since change of ownership of the home. The purpose of the visit was to conduct an unannounced inspection and to carry out an investigation regarding a complaint recently received by CSCI. The inspection focussed upon the requirements made at the last inspection. The complaint investigation concerned a resident who had left the home a number of months ago therefore; it was in relation to the previous homeowner. In order to determine the outcome a selection of documentation was examined including records maintained by both the previous and current owners. Two care plans of current residents were examined as well as the care plan of the resident in respect of the complaint. Case tracking was carried out regarding one current resident in order to identify if the home had addressed all of the individuals needs. A tour of the premises was carried out. The inspector held discussions with both of the new owners, the newly appointed cook, three residents and two care staff were formally interviewed. What the service does well: What has improved since the last inspection? A full time cook had been recently employed to improve the standards of food provided and to release care staff to carry their duties. All bedrooms had been supplied with new bedding and some rooms had been re-decorated. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 6 All aspects of documentation including policies and procedures were currently being re-written. The kitchen had been deep cleaned and had new windows fitted. Comprehensive staff files were being organised and care plans re-written to provide in depth information including personal preferences. Hygiene levels were significantly better throughout the home. 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 E54 S62525 Stoneleigh V227217 110505 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 E54 S62525 Stoneleigh V227217 110505 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 and 3 The homes statement of purpose, service user guide and contract of terms and conditions are incomplete therefore, current and prospective residents are unclear regarding the terms and conditions of residency and the range of services provided. Pre-admission assessments were being carried out in order to determine the homes ability to meet the individual’s needs. EVIDENCE: The registered person advised that the statement of purpose and service user guide were currently being developed and on completion a copy of the service user guide would be issued to each resident. Information was also provided in respect of the contract of terms and conditions of residency, which was being collated prior to being supplied to every resident. The home will need to complete the process to gain compliance with the respective standards. The care plan of the most recent admission had been utilised as the preadmission assessment tool. The assessment was seen to be comprehensive and the registered person said that a dedicated pre-admission assessment tool was being developed that will include all of the items listed in standard 3.3 of the National Minimum Standards. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 9 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 and 9 There is no consistent care planning system in place that provides staff with the information they need to satisfactorily meet resident’s needs. The system of administration of medications was satisfactory however staff had not received training, which potentially puts residents at risk. EVIDENCE: The care plans of two residents were examined, one being in relation to the most recent admission. The care plan, which had been developed by the previous homeowner, was found to be grossly inadequate. The care plan in respect of the latest admission was noted to be comprehensive, addressed all aspects of needs and included personal preferences and routines of daily living. The home will need to complete the transference of all residents to the new format. The file of the previous resident and relative of the complainant had been developed over a period of a few years, the content was noted to be very poor and no recordings were found during the latter period of her stay at the home or the date of admission to hospital. Two staff that were employed during this were formally interviewed. Both stated that in their opinion the standard of personal care afforded to the respective resident was of a satisfactory standard at all times. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 10 There was evidence that the advice of external professionals was being actively sought and acted upon and assistance provided to ensure that residents attended appointments with external health care professionals. The home has not introduced a system of regularly carrying out and recording the weights of each resident. The registered manager had recently formulated the written procedure for the administration of medications. The system in place for the ordering, receipt, storage, administration, recording and disposal of medications was determined to be satisfactory. The inspector was informed that training for staff in the safe administration of medications had been arranged. All staff must undergo appropriate training before participating in any aspect of the medication processes within the home. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 11 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, 14 and 15 The registered person acknowledged that the activities programme required significant development to achieve a varied and enriched lifestyle for all residents. There was scant written evidence that consultation with residents was taking place or that their views are sought and acted upon. The meals provided constituted a varied, wholesome and balanced diet. EVIDENCE: The activities programme was found to be in need of significant development however some progress was reported. An external visitor provides a movement to music session fortnightly, staff had brought jigsaw puzzles into the home and a resident had commenced knitting. The inspector was informed that adequate levels of consultation took place and that residents and visitors had reported a good improvement. With the implementation of the new care planning system the home needs to ensure that personal preferences are fully documented. The home also needs to establish regular residents meetings. The standard of food provided had recently been improved. The homes commitment to this was evidenced with the recent employment of a full time cook and from sampling of the lunchtime meal. There was evidence that residents are offered alternatives to the menu. The cook does not work Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 12 Fridays because three residents had requested a fish and chip meal, which had been actioned. The registered manager has a Food Hygiene certificate and works in the kitchen when the cook is not available. A diary of meals provided has also been introduced and in depth records maintained of food consumed by any resident suffering from a poor appetite. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 13 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) 18 only The home now has a written policy in respect of adult protection however; staff have not received training to ensure that an appropriate response to suspicion or allegation would be carried out. EVIDENCE: The written procedure that had been compiled by the registered manager included a policy in respect of whistle blowing. The lack of staff training in this aspect of care needs to be addressed thus providing staff with the knowledge and skills to act in accordance with the Birmingham City Council multi-agency guidelines. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 14 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, 22, 23, 24 and 26 The standard of the accommodation and décor within bedrooms and the communal areas had improved providing an attractive and homely place to live. Work in order to ensure the privacy of residents within their bedrooms remains outstanding. EVIDENCE: The home was found to provide hygienic and comfortable accommodation and it was noted that residents were now frequenting the conservatory. There is a choice of the large lounge with plasma television or the smaller quiet lounge. The home has a dedicated dining room with a conservatory leading from it with access to the rear garden. The large lounge had new lighting installed and the reception area had been reorganised with ornaments strategically placed to improve the overall appearance. The kitchen had been deep cleaned, new windows fitted and a complete replacement of food stocks and a system of stock rotation implemented. New table clothes and place settings had been purchased for the dining room and the inspector was informed of the plans to Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 15 enhance the appearance and access to the garden with the installation of decking. Some of the bedrooms had been refurbished and there was evidence of a programme of works to complete the process in all bedrooms. The rooms visited provided a much brighter and fresh look; the bedding had been replaced in all bedrooms. A blind has been fitted to the velux window of a bedroom in order to ensure the occupants privacy. The installation of lockable facilities in each bedroom and suited door locks remain outstanding requirements from pervious inspections. Advice was given that there has been no progress regarding increased assisted bathing facilities therefore, the requirement made from earlier inspections will be carried forward. The home has a comprehensive call system and a six person shaft lift. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 16 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, 29 and 30 There were safe numbers of staff allocated for the current number of residents. A robust recruitment process had been implemented thus ensuring the safety of the residents. Staff had not had relevant training to provide them with adequate knowledge and skills to meet the resident’s needs. EVIDENCE: Staffing levels consist of two carers and a manager during waking hours with one waking night and one sleep-in. The recent employment of a full time cook has served to enhance the role of care staff in the provision of personal care. Information was supplied that the home intends to employ a housekeeper. Regular staff meetings have been introduced and minutes circulated. An inspection of the personal file in relation to the recently employed cook was carried out. This provided information that the home was conducting safe practices in the selection and recruitment of staff. Unfortunately the files of other staff generated by the previous owner were of a poor standard. The new owners were in the process of introducing a logical system of maintaining staff files. Although staff had not received mandatory or relevant training the home had taken steps to address this issue. Training had been arranged for the National Minimum Standards, Safe Medication and Incontinence. Other training, which the home needs to address, are Manual Handling, First Aid, Fire Safety, Food Hygiene and Adult Protection. One member of staff has commenced NVQ level 2 training. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 17 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, 35, 36, and 38 There is strong leadership and direction to ensure that residents receive a consistent quality of care. Some practices do not promote and safeguard the health and safety of residents. EVIDENCE: Both of the new owners have had relevant experience in the care sector, the registered manager is suitably qualified and one of them remains on the premises at all times. From the interviews carried out with care staff, both reported an improved management approach and gave examples of enhanced levels of support for residents and staff. There was no evidence that the previous homeowner had retained receipts or records in respect of monies spent on behalf of residents. The system in place at the time of the visit was found to be satisfactory in all aspects. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 18 The current induction programme was deemed to be inadequate. The home needs to implement an induction programme that reflects the contents of the TOPSS programme. The registered manager advised that the written policies and procedures were being developed but had not been completed at this stage. The home had collated appropriate documentation for formal staff supervisions, one meeting had taken place. The home needs to fully implement the system. It was reported that no progress in making the garden safe for access however; information was given that this would be addressed and formed part of the maintenance programme. The registered manager had commenced undertaking of risk assessments for residents but that they had not been completed. The risk assessments for staff, the premises, fire and food were also outstanding. Arrangements had been made for the testing of the water storage tanks’ the home was advised to commence regular random testing and make recordings of hot water outlets that residents come into contact with. Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 19 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 2 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 3 x x 3 2 x 2 Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and 5 Requirement The statement of purpose must be completed and include all information as required in Schedule one. The service user guide must be developed and a copy supplied to each resident. Residents must be issued with a contract of terms and conditions, which includes all items listed within Standard 2.2. The home must develop and utilise a pre-admission assessment tool that includes all items listed with Standard 3.3. The transistion of all care plans to the new system must be completed. Regular reviews must be undertaken. Monthly weights must be carried out of each resident and records of such maintained. Staff must receive appropriate training before administering medications. N.B. Training has been arranged. The registered person must provide evidence that residents are being consulted regarding their preferred activities. A programme of activities must be Timescale for action 31st July 2005 2. OP2 17(1)a Schedule 3 14(1)a 31st July 2005 30th June 2005 31st July 2005 31st July 2005 14th August 2005 31st July 2005 3. OP3 4. OP7 15 5. 6. OP8 OP9 13(1)a,b 13(2) 7. OP12 16(2)m Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 21 8. 9. 10. OP14 OP18 OP24 16(2)m,n 13(6) 16(2)l 11. OP24 16(2)b 12. OP28 18(1)c 13. OP30 18(1)c 14. 15. OP33 OP36 24 18(1)c,i formulated and on display within the home. The registered person must hold regular residents meetings and circulate minutes accordingly. All staff must receive training in adult protection. The registered person must provide a lockable facility for each resident to keep valuables in their bedroom. The registered person must change the bedroom door locks to a suited design, which permits staff access in the event of an emergency. 50 of care staff employed should heve completed NVQ level 2 training or equivalent. N.B. Not assessed at this visit but carried forward. Training for staff in Health and Safety, Food Hygiene, First Aid, Manual Handling and Fire Safety must be provided. N.B. Work had already commenced in addressing this requirement. The home must implement a system of quality assurance. The homes induction programme must be further developed to include all items listed in the TOPSS training schedule. The home must complete the process of regular formal staff supervisory meetings and maintain documenation of such. The home must complete the process of carrying out risk assessments for all residents and undertake risk assessments in respect of staff, fire, the premises and food. Regular random testing of hot water outlets that residents 31st July 2005 31st August 2005 31 August 2005 30th September 2005 30th September 2005 30th September 2005 31st October 2005 31st July 2005 31st July 2005 31st July 2005 16. OP36 18(2) 17. OP38 13(4)a-c 18. OP38 13(4)a 30th June 2005 Page 22 Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 19. OP38 23(2)o come into contact with must be recorded. The registered person must ensure adequate access to the garden and fitting of handrails where applicable whilst ensuring safety is maintained. 30th September 2005 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 Good Practice Recommendations Stoneleigh E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 E54 S62525 Stoneleigh V227217 110505 Stage 4.doc Version 1.30 Page 24 - 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!