Inspection on 23/11/05 for Stoneleigh

This inspection was carried out on 23rd November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stoneleigh 12/07/06

Stoneleigh 11/05/05

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 Retirement Home 19 Victoria Road Stechford Birmingham West Midlands B33 8AL Lead Inspector Kath Strong Announced Inspection 23rd November 2005 09:50 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 Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 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 Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stoneleigh Retirement Home Address 19 Victoria Road Stechford Birmingham West Midlands B33 8AL 0121 628 6099 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) Mrs Pamela Sale Mrs Ann Patricia Smith Mrs Pamela Sale Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That in addition to the care manager that there are a minimum of two care staff on duty throughout the waking day. That at night the minimum staffing levels of one person on waking night duty and one person on sleeping in duty are maintained. Ancillary staff are to be employed in addition to the minimum staffing levels to cover catering and cleaning. The ramped access at the side of the building is to be improved and enhanced to provide access into the building for people who experience mobility difficulties within six months of registration. Handrails are to be fitted next to the garden steps within six months of registration. Shower facilities within the home are to be improved to floor draining level access over a period commencing from six months of registration and completed within twelve months of registration. Additional aids and adaptations within bathrooms, toilets and shower rooms are to be fitted as guided by an occupational therapist within six months of registration. Temperature control valves are to be fitted to showers within the home within a period not exceeding three months of registration. Bedroom doors are to be fitted with suited locks within twelve months of registration. Velux windows are to fitted with window blinds within three months of registration. A guard or cover for the radiator in the en-suite shower room is to be fitted within three months of registration. 11/05/05 5. 6. 7. 8. 9. 10. 11. Date of last inspection Brief Description of the Service: Stoneleigh is an adapted domestic property located within the residential 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 located on the two upper floors and a single room is Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 5 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 staged 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 Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the first announced inspection of the home following change of ownership early this year. Many requirements were generated during the previous ownership. This visit has focussed upon the majority of the standards; the outcome was determined by various means. The two home owners participated with the full inspection and in depth discussions were held with them. Three residents and two relatives were spoken with individually and two members of staff were interviewed. Relevant documentation was examined including two care plans, one of which was case tracked in order to ensure that all identified needs were being met. A tour of the premises was conducted. At the conclusion verbal and written feedback was given to both owners. No immediate requirements were necessary. What the service does well: What has improved since the last inspection? Excellent improvements have been achieved; resulting in a significant reduction of the requirements, which were a legacy of the last owner. A good proportion of the conditions of registration have been addressed. All unnecessary items and clutter have been disposed of. All communal rooms have been redecorated and new curtains hung. The lounge and dining room carpets have been replaced. The armchairs in the lounge have been replaced. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 7 All bedrooms have been redecorated including new quilts and curtains. The showers on the ground and second floors have been replaced. The floor of the ground floor shower has been professionally assessed and deep cleaned. A lockable bedroom facility has been supplied for those residents who request it. The rear garden has been re-designed to include decking, handrails, seating, features and pot plants. The majority of the lighting has been replaced with domestic style lighting. A variable height bed has been purchased. Hygiene levels throughout the home have significantly improved. The front exterior to the building has been re-painted. 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 Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 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 Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Documentation provide to prospective residents is adequate for them to make an informed decision about the home. Pre-admission assessments are carried out demonstrating the home’s ability to meet identified needs. EVIDENCE: The statement of purpose and service user guide contain sufficient information to satisfy the standard. The service user guide includes pictures resulting in a pleasing effect for the reader. The contract of terms of residency has been completed and the registered manager advised that it would be distributed to each resident. The tool utilised for pre-admission assessments is further expanded on admission to form the framework of the care plan. The home is currently developing a dedicated pre-admission tool, which will complement the current documentation. Pre-admission assessments are carried out by one of the owners at a venue convenient to the prospective resident. Relatives and the prospective resident are invited to visit the home, socialise with staff and residents, sample the food and overnight or weekend stays can Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 10 also be arranged. Following admission a trial period of 28 days is provided prior to a placement being confirmed. A resident is currently being re-assessed by external professionals who have determined that in order to fully meet his needs nursing home care will need to be arranged. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The arrangements for care planning are comprehensive and include clear staff guidance on how the identified needs should be met. The system for the administration of medications needs to improve to ensure full safety practices are carried out. Observations revealed that the privacy and dignity of residents is respected. EVIDENCE: A new care planning system has been introduced and is determined to be a significant improvement. Files included assessments, physical and mental health care needs. Relevant risk assessments should be expanded outlining the action to be taken to minimise risks. There are dedicated records in respect of GP, Chiropodist and District Nurse visits, monthly weights and skin discolouration charts. The activities of daily living are well documented including likes/dislikes and preferences. Files contain life histories, hobbies and social and recreational preferences. There is good evidence of the involvement of external professionals and that their advice is acted upon. Some improvements are required to the process for the administration of medications. The administration is currently restricted to the home owners until staff have completed appropriate training. Advice was given that training Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 12 has been booked for staff. Although the inspector was assured that all medications received are audited, this must be verified on the respective MAR (medication administration record) charts. Prescribed topical medications must be stored in a dedicated drugs fridge and the temperature recorded daily. From observations and comments received from residents and relatives residents privacy and dignity is ensured. Staff were noted to be using the preferred term of address and personal care was delivered in the privacy of a bathroom or the bedroom. When a resident is very ill they are given the option of remaining at the home or being admitted to hospital. The decision is made in consultation with the family and health care professionals. The services of District Nurses and McMillan Nurses are currently being utilised for a resident. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 12, 13, 14, 15 The recreational facilities are steadily being developed; residents must be given prior notice of the programme available. Residents are consulted about the day to day operations of the home. Dietary needs are well catered for with a balanced and varied selection of foods available that meets individual tastes. EVIDENCE: Activities offered are varied and being further developed. External entertainers are invited to the home including regular movement to music. Spiritual needs are met by visiting clergy. The proposed Christmas celebrations include a travelling pantomime, a carol service and a party with relatives invited to attend. Two residents plan to go to relatives on Christmas day. One resident goes out regularly, relatives or staff escort her. Another resident goes out independently and enjoys carrying out light shopping tasks on behalf of the home. There is no formal programme in place at present; residents must be given ample notice by provision of written details of forthcoming events. Regular residents meetings have been established with minutes being distributed accordingly. Members of the legal profession are able to make appointments and the home offers an advocacy service from an external source. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 14 The home has compiled a rolling menu; lunch is the main meal of the day. The menu indicated that a balanced diet is provided and that alternatives are always available. All requests are catered for at breakfast and a light meal is supplied each evening. On the day of the inspection residents were being given mid morning toasted crumpets and tea; the registered manager advised that this is a daily event. Some residents enjoy an alcoholic drink during the evenings and sherry is offered with Sunday lunch. Residents spoken with provided positive feedback and a relative said, “Food is absolutely beautiful”. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 16, 18 Residents opinions are listened to and acted upon, the complaints procedure is satisfactory. The arrangements for the protection of residents are satisfactory. EVIDENCE: The complaints procedure is comprehensive and available to residents and relatives. There is a tool for the logging and monitoring of complaints. The home has received one formal complaint since the change of ownership. This was upheld and dealt with appropriately by senior staff. The written policy regarding adult protection provides adequate information and instruction to staff in how to respond to concerns raised or witnessed. There is also a policy advising about whistle blowing. Staff have had training in adult protection and dealing with challenging behaviour. The two staff interviewed displayed appropriate knowledge and their responsibilities where there is an allegation of abuse. The recently appointed member of staff ahs been enrolled to receive training January 2006. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 19, 20, 21, 24, 25, 26 Residents live in a warm, comfortable and safe environment. The premises are tidy and hygienic throughout. EVIDENCE: The new owners should be commended for the significant improvements made to the fabric of the building. As stated in the summary of this report many improvements have been achieved. The main lounge is bright and airy, the dining room offers a choice of three large tables and the conservatory leading off provides a quiet area. The rear garden has been landscaped and now provides decking with handrails, garden features, seating and pot plants. Hygiene levels have improved dramatically with special attention given to the kitchen. The housing of the laundry facilities remains basic; the registered manager stated that improvements are planned for next year. There are toilets and bathrooms strategically located throughout the home. Two showers have been replaced and there are plans to refurbish the bathroom when it is proposed to increase the assisted bathing facilities. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 17 The refurbished bedrooms are pleasant, and are well personalised. New furniture has been purchased for many of the rooms, a lockable facility is provided for those who request it. Suited bedroom door locks have not been fitted, this needs to be addressed. There is a comprehensive call system and a shaft lift, which can accommodate up to six persons. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff morale is high resulting in an enthusiastic workforce that works positively to improve resident’s quality of life. Further staff training is needed to ensure the safety of residents. EVIDENCE: Two carers and a manager are on duty during daytime hours and there is one carer at night with a senior person providing a sleep-in service. Currently the number working a waking night has been increased to two due to the dependency levels of residents. This will remain under review according to the needs of residents vary. A member of staff was observed providing a verbal handover to another. It was also noted that as far as practically possible a member of staff is present in the lounge and dining areas. The home also has a full time cook who displayed in depth knowledge of residents preferences. The registered manager also covers kitchen duties for two days per week. A housekeeper has been employed since the last inspection. Recruitment practices were found to be satisfactory with all relevant checks being carried out prior to a post being confirmed. Newly appointed staff are expected to undertake TOPSS induction programme. The home is working towards 50 of staff completing NVQ level 2 training. Some mandatory training has been supplied and other courses have been arranged for Fire Safety and Health and Safety. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 19 One member of staff interviewed said, “Standards have improved because we are getting training”, “The atmosphere has changed, staff know what they need to do, defined roles”. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Senior staff have a well defined development plan and vision for the home, which is effectively communicated to residents and staff. The staffing structure provides clear lines of accountability. The programme of staff training and formal supervision must be completed to ensure the safety of residents. EVIDENCE: Both owners have a wealth of experience within the care sector. One is the registered manager; she is suitably qualified for the role. Both owners demonstrate strong leadership and lead by example. A resident said, “These two are brilliant, no complaints”. The home has not established a quality assurance system but improvements have been made and residents and relatives views are welcomed and acted upon. Comment cards were received from nine relatives, one GP, a McMillan Nurse and a Social Worker. All were complimentary with one slight exception. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 21 The personal monies of two residents are paid by Social Care and Health directly into the homes business account. There is a clear means of identifying and tracking individual’s monies. It is recommended that a separate account should be established and that any subsequent interest accrued should be paid to residents. Regular staff meetings are held with minutes circulated accordingly. Regular formal staff supervisory meetings have been commenced but are not fully established. A file of policies and procedures has been compiled. Resident’s files are stored in a locked cupboard in the dining room; staff have access to them at all times. Accredited contractors have carried out all servicing and checking of equipment. Weekly fire alarm testing and regular fire drills are carried out but the home has yet to establish monthly testing of the emergency lighting. The homes risk assessments in respect of the premises, staff, fire, food and infection control were not examined on this occasion. The home is advised that these will be reviewed at the next inspection. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 2 Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Staff must receive appropriate training before administering medications. N.B. Training has been arranged. Audits of medication received must be verified in writing. Prescribed topical medications must be stored in a dedicated drugs fridge. A programme of activities must be formulated and on display within the home. The registered person must change the bedroom door locks to a suited design, which permits staff access in the event of an emergency. N.B. Not met from the previous inspection. 50 of care staff employed should have completed NVQ level 2 training or equivalent. Training for staff in Health and Safety and Fire Safety must be provided. N.B. Arrangements have been made for staff training. The home must implement a system of quality assurance. DS0000062525.V260031.R01.S.doc Timescale for action 31/12/05 2. 3. OP12 OP24 16(2)m 16(2)b 31/01/06 31/03/06 4. 5. OP28 OP38OP30 18(1)c 18(1)c 31/03/06 15/01/06 6. OP33 24 31/03/06 Stoneleigh Retirement Home Version 5.0 Page 24 7. OP36 18(2) 8. OP38 13(4)a-c 9. OP38 13(4)a N.B. This requirement is carried forward. The home must complete the process of regular formal staff supervisory meetings and maintain documentation of such. The home must complete the process of carrying out risk assessments in respect of staff, fire, the premises and food and infection control. N.B This has not been inspected and therefore carried forward. The registered manager must establish monthly testing and recording of the emergency lighting. 15/01/06 28/02/06 15/12/06 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. Refer to Standard OP7 OP35 Good Practice Recommendations The registered manager is requested to review the risk assessment tool to provide detailed action to be taken to minimise the risk. It is recommended that a separate account be established for storage of resident’s personal monies. Stoneleigh Retirement Home DS0000062525.V260031.R01.S.doc Version 5.0 Page 25 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. 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