Inspection on 14/04/05 for Stonesby Lodge

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Stonesby Lodge 03/08/09

Stonesby Lodge 14/08/08

Stonesby Lodge 19/09/07

Stonesby Lodge 25/07/06

Stonesby Lodge 04/01/06

Stonesby Lodge 09/09/04

Stonesby Lodge 06/05/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Stonesby House 147 Stonesby Avenue Wigston Leicestershire LE2 6TY Lead Inspector Ruth Wood Unannounced 08 July 2005 16:15 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stonesby House Address 147 Stonesby Avenue Wigston Leicestershire LE2 6TY 0116 283 1638 0116 283 1638 Stonesby_House@Hotmail.co.uk Mr Osman Amar Saghir 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) Mrs Sylvia Ann Martin Care Home 11 Category(ies) of MD Mental Disorder(11) registration, with number of places Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/11/2004 Brief Description of the Service: Stonesby House provides a service for eleven adults with mental health needs under the age of 65. The home, an extented semi- detached house, is situated on the main Stonesby Road close to shops and other amenities. There is a bus stop near to the home and regular bus service to Leicester and Wigston. There are two double and two single bedrooms upstairs with a further five single bedrooms downstairs. All except one bedroom have full en-suite facilities. The home has a large, open plan lounge/dining room and an additional room, recently added to the building in which service users can smoke. This room is conservatory style with minimal furniture. There are very small garden areas to the front side and rear of the property which are predominantly paved. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection which took place on Friday 08/07/05 between 4.15pm and 9.30 pm. Planning for the inspection took approximately 4 hours and included reviewing the details of a Complaint received immediately prior to the scheduled date of the inspection. The Inspection therefore focussed primarily on those Standards relating to issues raised in the Complaint. Previous inspection reports were also reviewed together with correspondence. Several aspects of the complaint led to a vulnerable adults referral being made to placing authorities and discussions are ongoing with social workers from these authorities concerning the care needs of individual service users. A joint investigation as to whether aspects of the service place service users at risk is still on going. Because of the nature and extent of the complaints made two inspectors undertook the majority of the inspection. Following the first inspection visit, Immediate Requirements were left with regards to medication and electrical safety. These have now been met. The Inspection visit continued during a separate Unannounced Visit between 8.45am and 1.30pm on 12/07/05. A final visit was made on 13/07/05 to assess the response to the Immediate Requirements. Regular visits will continue to be made to the home to monitor progress in response to the 49 Requirements and 3 Recommendations made. What the service does well: What has improved since the last inspection? What they could do better: The information given to prospective service users does not accurately reflect the kind of service users the home can care for; information about the home’s staff and staffing arrangements is also inaccurate. Improvements are needed in the writing and implementation of service users’ assessments and care plans. How service user choice and ability to take risks is managed needs improvement. Currently too many restrictions are placed upon service users’ Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 6 actions with insufficient evidence given as to why these are in place. Conversely service users are placed at risk by some practices in the home and there is no clear system of assessing those risks. There are too many restrictions placed on service users with regards to what they can eat, when and where. Improvements are also needed in the choice and quality of food served as well as the hygiene standards of the kitchen and staff team. The home’s current management and administration of medication is very poor. Many staff require training in this area and improvements are needed in how medication is stored, recorded and managed. Service users also need to be actively supported by staff when administering aspects of their own medication. Considerable improvements are needed in the home’s environment. The general standard of hygiene in the home is poor particularly in the kitchen and bathroom areas. Several carpets are stained and need replacing or cleaning, plaster in some rooms is cracked or damaged and fittings in the home such as toilet seats are broken. There is also insufficient lighting in many areas and the wall lamp in one service user’s room was in a dangerous condition. Improvement is also needed in how hazardous substances (such as household cleaners) are stored and managed within the home. At times, staffing levels are insufficient to meet the needs of service users and there is a lack of clarity about the role of some staff within the home. Some staff have not had Criminal Records Bureau checks, neither has the home received written references for some staff. Considerable improvement is needed in many aspects of management and administration in the home. Policies and procedures are currently written from the perspective of older persons meaning they are not fully relevant to the service users living in the home. In addition policies and practices to protect service users from abuse are inadequate. Improvements are needed in the management of service users’ personal finances as the records relating to these were unclear and receipts and other evidence of expenditure are not routinely kept. 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. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5 Key information about the home’s services is inaccurate and some aspects of users’ terms and conditions are not clearly documented. Together with poor assessment systems this results in service users being poorly informed and a high risk of their needs not being met. EVIDENCE: The Statement of Purpose given to Inspectors stated that the home is dually registered to provide care for people with mental disorder and learning disabilities. This is inaccurate; the home is not registered to provide care for people with learning disabilities. The Statement also did not accurately reflect the staffing arrangements for the home and the qualifications and experience of the staff currently working within the home. Social work &/or Community Psychiatric Nurse assessments were available for all service users, however several of the home’s own service user assessments were incomplete and undated. Patterns of care (such as the limitation of cigarettes for certain service users) had been inherited and continued by the home with no evidence that their appropriateness or relevance had been assessed on admission. Reference is made in some service users’ files to written and verbal warnings for service users. No policy or procedure was in place within the home as to under what circumstances these would be issued, by whom and the consequences of receiving them. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 9 A service user with a hearing disorder was not being fully supported by staff to manage this effectively. Equipment needed by this service user was poorly maintained. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Risk management and documentation within the home is poor; some practices within the home place unnecessary restrictions on service users while others place service users at unnecessary risk. EVIDENCE: All service users’ files contained a care plan but many of these were incomplete and undated. Those plans that were dated demonstrated that some had not been reviewed for in excess of 12 months. Agreements in some service users’ files restricting behaviour (e. g. with regards to smoking) had not been signed or dated by the service user. There were few risk assessments within care plans. Those that were in place were frequently not dated, signed or written in sufficient detail neither did they show evidence of regular review. For example in one service user’s file an undated and unsigned entry was made stating that the service user was no longer to administer their own medication. Several cupboards within the kitchen are kept routinely locked as is the refrigerator and freezer. A notice on the kitchen door stated that the kitchen was locked overnight and not available between certain hours in the evening. An entry in one service user’s care notes indicated that they did not have access to butter for their toast until a certain time in the evening. A drawer Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 11 containing sharp knives (not in a knife block) was unlocked. No risk assessments were in place for individual residents documenting why they should not have access to items within the kitchen. No risk assessments were in place detailing the potential risks from items such as knives and how these should be managed. One service user leaves the home for extended periods. An agreement is in place that should their absences extend beyond 24 hours the police and placing social worker are to be informed. The documentary evidence in the home suggests that this procedure is not always followed Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 Service users’ diet currently lacks nutritional balance and variety and unacceptable restrictions are placed on service users with regards to what, where and when they can eat. EVIDENCE: On the initial day of inspection the range of fresh foods within the home was limited to cheese and cucumbers leading to a restricted choice for service users’ evening meal. Fresh vegetables were sprouting and/or decayed. Eggs in the home were not date stamped, were kept outside of a refrigerator (during a period of very warm weather) and many were stale. Meat stored in the home’s freezer was not marked or dated and was wrapped inadequately. Several items such as canned cream and mayonnaise were stored in store cupboards rather than refrigerated; several such items were also beyond their use by date. None of the home’s staff have a Certificate in Food Health and Hygiene. Only UHT semi-skimmed milk was available for service users’ use. Certain restrictions are placed on service users as to what they can eat, where they can eat and when they can eat. The home’s Statement of Purpose states that the home does not provide pork products and the majority of the meat Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 13 served in the home is halal meat. Service users are advised that they can purchase and eat non halal products within their own rooms. Signs on the kitchen door indicated that the kitchen was not accessible to service users for extended periods and information within care notes suggested that food was only available at certain times. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) ,20 The home’s medication administration systems and practice are very poor and place service users at risk. EVIDENCE: Very large quantities of medication were discovered, stored in cardboard boxes in a locked cupboard under the stairs. Medication included that being currently dispensed, skin creams, ‘as required’ medication and inhalers for asthma. Household cleaning products such as bleach were also stored in this cupboard which housed the home’s electricity meter and fuse box. Some medication had been issued by the pharmacist over 1 year ago. An Immediate Requirement was left for the home to return excess medication. This was met on 09/07/05 and documentary evidence supplied on 13/07/05. Medication supplied that day by the pharmacist was left in a plastic box on the floor of the unlocked office for the duration of the first day of inspection. The office door was propped open for large periods of time. Several service users’ medication administration records contained gaps where there was no signature and the code ‘0’ (meaning other) frequently appeared but no reason was documented as to what this meant. A staff member stated that they were being trained to administer medication by the home’s Deputy Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 15 manager. Their description of the process indicated that during this process they were not being directly or adequately supervised. The Deputy Manager stated that most service users administered their own inhalers and skin creams. No risk assessments were in place with regards to these processes neither was their evidence of periodic checks to ensure that service users remained able to undertake this. The Manager, Deputy Manager and one Senior Carer hold certificates stating that they have received training from their pharmacist in the administration of medication. The dispensing pharmacist had visited on 30/06/05; their report stated that there were no problems with medication administration in the home. Service users’ care plans did not state under what circumstances ‘as required’ medication can be administered and by whom. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Existing policies and practices within the home do not protect service users from abuse, neglect and self-harm. EVIDENCE: There were no clear policies or procedures within the home dealing with the management of challenging behaviour, protection of vulnerable adults or whistle blowing. Incidents of challenging behaviour were not clearly documented and the Commission for Social Care Inspection have not been notified of such incidents. The Registered Manager and the Deputy Manager were unclear as to policies regarding service users’ monies. The balance of one service user’s money was checked against records kept and was £40 in excess of the recorded balance. Records for service users’ financial records were poorly kept. There were no receipts available for alcohol and cigarettes purchased on behalf of service users and later charged to their account. A service user reported that they had experienced money going missing. There appeared to be no clear procedure as to how the home responded to this. Poor practice in this area has been highlighted at previous Inspections. Some staff working within the home have not had a Criminal Records Bureau check. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 Standards of hygiene within the home are very poor and considerable improvements are needed to ensure that service users live in a comfortable and safe environment. EVIDENCE: On arrival at the home it was observed that the fire door from the corridor to the office area was propped open with patio cleaner. Several areas of the home had insufficient lighting. The majority of lights in en-suite facilities were not working. A very low wattage bulb was used in the upstairs bathroom. The stairs and landing area was insufficiently lit. In one service user’s bedroom a light fitting was in a dangerous state with bare wires exposed. An immediate requirement was left and by 13/07/05 this had been made safe. The majority of toilet seats in en-suite bathrooms were broken. Some ensuites were not supplied with toilet roll and soap. All en-suite bathrooms (with one exception) required cleaning. One bathroom’s tiles were heavily stained with urine and there was a strong smell of urine in the room. In another bathroom a service user had not been provided with a means of disposing of their incontinence pads. Consequently their bathroom smelt strongly of urine. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 18 There were broken floor tiles in the upstairs bathroom. One service user’s bedroom carpet was heavily stained and smelt strongly of urine. Several bedroom carpets were stained. The landing area carpet was dirty. Requirements have been made at previous Inspections with regards to the standard of hygiene in the home. The temperature at all hot water outlets was tested and was below 43 degrees centigrade however there was no hot water for the shower in the upstairs bathroom. The Deputy Manager explained that hot water was not routinely available in the evenings unless requested by the service users. The kitchen floor and services were dirty and required cleaning – By 12/07/05 floors and surfaces were clean. Three tea towels being used in the kitchen were extremely dirty; mugs used by service users were cracked and chipped. The refrigerator, deep fat fryer and kitchen extractor required cleaning. The refrigerator and freezer also required defrosting. Mops used in the kitchen and bathroom areas are both the same colour leading to possible confusion as to which is used where. The filling was coming out of one service user’s quilt. Laundry was left on the floor of the corridor outside of the laundry. Old coffee tins were used as for ash disposal in the smoking area. Large cracks were evident around the door of the ground floor bedroom nearest to the front door. Another downstairs bedroom had wall cracks and plaster missing from the walls. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34 Insufficient staffing levels, poor recruitment practices and the lack of clarity about the role of some staff do not ensure the protection of service users. EVIDENCE: On arrival on the first day of inspection there was one staff member on duty with 11 service users at home. The home’s deputy home manager arrived 30 minutes later. All staff records were examined. Three members of staff have had no Criminal Records Bureau check. There were no references on file for three staff and only one reference on file for another staff member. There was uncertainty as to the status and length of time one staff member had been in the home. At the initial inspection visit the staff member was described as carer who had been at the home a few days and was being trained. On the second visit they were entered on the rota as a cleaner but were observed preparing lunch in the kitchen. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 42 Service users’ rights and best interests are not safeguarded by the home’s current policies and procedures. The health, safety and welfare of service users is not well promoted and protected in the home. EVIDENCE: The majority of policies within the home are written to meet the National Minimum Standards for Older People rather than the Standards for Younger Adults. Many of the policies are therefore inappropriate. Some policies refer to practice in nursing homes again not relevant to the home’s service user group. On the first day of inspection it was noted that portable electric appliances had not been tested – an immediate requirement was served requesting that the home complete this work by 11/07/05. The work was completed by13/07/05. On the first day of inspection patio cleaner was found propping a fire door open and bleach and other cleaning products were found stored alongside medication. On two subsequent visits cleaning products were appropriately Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 21 stored. The home’s Control of Substances Hazardous to Health assessment was not available for inspection. Incidents affecting the safety and welfare of service users have not been reported to the Commission for Social Care Inspection as required. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 2 x 1 Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 1 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 1 Standard No 11 12 13 14 15 16 17 x x x x x x 1 Standard No 31 32 33 34 35 36 Score 2 x 1 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stonesby House Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x x x 1 x 1 x C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 23 Yes 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 1 Regulation 4 Requirement The Registered Person must ensure that the Statement of Purpose accurately reflects the registration status of the home. The Registered Person must ensure that the Statement of Purpose accurately reflects the numbers of staff deployed in the home and their level of qualification and experience. The Registered Person must ensure that the current needs of service users are fullyassessed on admission to the home and that assessments are clearly documented and dated. The Registered Person must ensure that the identified service users needs are met with regards to their hearing loss. The reasons why service users would be issued with verbal and/or written warnings must be clearly documented within the service users terms and conditions. Service users and/or their representatives must be made aware of these conditions. Who has the authority to issue such warnings should also be documented. C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Timescale for action By 05 August 2005 By 05 August 2005 2. 1 4 3. 2 14 With immediate effect 4. 3 12 By 12 August 2005 By 12 August 2005 5. 5 5 Stonesby House Version 1.40 Page 24 6. 6 15 7. 7 15 The Registered Manager must ensure that each service user has an up to date care plan, which accurately reflects their current needs. This care plan must be signed by the assessor, the service user and be dated. The Registered Manager must ensure that service users plans are regularly reviewed. Restrictions on service users choices must be clearly documented within service users individual plans together with the reasons why these restrictions have been imposed. All such documentation must be signed and dated by the services user and the assessor (Previous timescale of 08/01/05 not met). Risk assessments must be put in place to ensure that service users are supported to take responsible risks without placing themselves in unecessary danger. The home must respond to the absence of the identified service user in the manner agreed with the placing authority. All staff involved in the preparation and serving of food must undertake accredited training in food health and hygienel The Registered Provider must ensure that food is stored safely and appropriately within the home. Food which is stale, decayed or past its given use by date must be destroyed. The Registered Provider must ensure that a varied and nutrious diet is available which reflects the cultural and religious requirements of service users C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc By 19/08/05 8. 7 13 With immediate effect and ongoing By 12/08/05 9. 9 13 By 19/08/05 10. 9 13 11. 17 18 With immediate effect and ongoing By 05/09/05 12. 17 16 With immediate effect and ongoing With immediate effect and ongoing Page 25 13. 17 16 Stonesby House Version 1.40 living in the home. 14. 17 16 Any restrictions placed on when service users can access food must be clearly detailed in their individual care plans together with the reasons such restrictions are in place. Any restrictions placed on where service users can eat must be clearly detailed in their individual care plans together with the reasons such restrictions are in place. Any restrictions placed on what service users can eat must be clearly detailed in their individual care plans together with the reasons such restrictions are in place. The Registered Manager must ensure that unused medication is returned promptly to the dispensing pharmacist and documentary evidence obtained of its return All medication must be stored appropriately and securely in the home. All staff who administer medication must receive appropriate training. The Registered Manager must ensure that Medication Administration Records are accurately completed and that the cause of any gaps in records is investigated The use of 0 in the Medication Administration Record to denote other must also include an explanation as to what other means. Individual risk assessments must be completed for those service users administering some of their own medication. These C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc By 12/08/05 15. 17 16 By 12/08/05 16. 17 16 12/08/05 17. 20 13 With immediate effect and ongoing With immediate effect and ongoing. 05/09/05 With immediate effect and ongoing With immediate effect and ongoing By 12/08/05 18. 20 13 19. 20. 20 20 13 13 21. 20 13 22. 20 13 Stonesby House Version 1.40 Page 26 23. 20 13 24. 23 13 25. 26. 23 23 13 13 27. 23 37 28. 23 12 29. 23 17 30. 31. 32. 23 24 24 18 16 23 must be regularly monitored and reviewed. Staff being trained to administer medication must be directly supervised by a senior member of staff throughout the whole process. A policy detailing the appropriate response to challenging behaviour by care staff must be written. This must include details as to how more vulnerable residents are to be protected. A policy on whistleblowing must be written and implemented within the home. The Registered Person must ensure that all staff are aware of the Multi- Agency policy relating to the Protection of Vulnerable Adults from Abuse. The Registered Person must ensure that CSCI is informed of all incidents as detailed in Regulation 37. The Registered Person must ensure that robust procedures are followed to ensure that service users money is safe within the home. The Registered Person must ensure that clear records, including receipts are kept of any purchase made by staff on behalf of service users. All staff must receive training in how to manage challenging behaviour from service users. The Registered Person must ensure that there is sufficient lighting in each area of the home The Registered Person must ensure that fire doors are not routinely propped open. The Registered Person must ensure that cracks in the identified bedrooms are repaired C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc With immediate effect and ongoing By 26/08/05 By 26/08/05 By 26/08/05 With immediate effect and ongoing By 12/08/05 With immediate effect and ongoing By 30/09/05 By 05/08/05 With immediate effect and ongoing By 15/09/05 Page 27 33. 24 23 Stonesby House Version 1.40 and plaster work is made good. 34. 30 16 The Registered Person must ensure that all areas of the home are kept clean hygenic and free from offensive odours. (Previous timescale of 08/11/05 not met. The Registered Person must ensure that food preparation areas and all equipment are kept clean and in good repair. The Registered Person must ensure that all the homes toilet seats are repaired or replaced. The Registered Person must ensure that all stained carpets within the home are cleaned or replaced. (Previous timescale of 05/11/05) not met. The identified resident must be provided with an appropriate recepticle in which to dispose of their incontinence wear The Registered Person must ensure that service users have access to hot water at all reasonable times. The identified service users quilt must be replaced Broken tiles in the upstairs bathroom must be repaired or replaced. The Registered Person must ensure that staff are clear about their roles and responsibilities within the home The Registered Person must ensure that there are sufficient staff on duty at all times to meet the needs of residents. The Registered Person must obtain Criminal Record Bureau checks for all staff working at the home. The Registered Person must ensure that no further staff are employed unless they have a valid CRB. C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc with immediate effect and ongoing With immediate effect and ongoing By 05/08/05 By 26/08/05 35. 30 16 36. 37. 24 30 23 23 38. 30 16 By 29/07/05 With immediate effect and ongoing By 29/07/05 By 26/08/05 With immediate effect and ongoing With immediate effect and ongoing By 05/09/05 With immediate effec and ongoing Page 28 39. 24 16 40. 41. 42. 24 24 31 16 23 18 43. 33 18 44. 34 17 45. 34 17 Stonesby House Version 1.40 46. 34 18 47. 40 17 48. 42 13 49. 42 13 Two written references must be obtained for all staff members before they are employed by the home. Two written references must be obtained for all exisiting staff. The Registered Person must ensure that the homes policies and procedures are appropriate to the service users living there. A Control of Substances Hazardous to Health Assessment must be undertaken and made available for inspection. The Registered Person must ensure that all substances hazardous to health are stored appropriately at all times. By 26/08/05 By 30/09/05 By 19/08/05 With immediate effect and ongoing 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 24 30 30 Good Practice Recommendations It is recommended that more suitable containers are obtained for the disposal of cigarette ash than the empty coffee tins currently used. lit is recommended that a laundry basket is placed outside the laundry door to enable service users to place dirty laundry in this rather than on the corridor floor. It is recommended that the 2 mops used in the kitchen and bathroom areas be distinctly labelled to prevent cross contamination. Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 29 Commission for Social Care Inspection The Pavillions 5 Smith Way, Grove Park Leicestershire LE19 1SX 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 Stonesby House C51 C01 S28065 Stonesby Lodge V237598 080705 STAGE 4.doc Version 1.40 Page 30 - 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!