Inspection on 29/09/05 for Stoneswood

This inspection was carried out on 29th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stoneswood 16/12/08

Stoneswood 31/01/08

Stoneswood 27/06/06

Stoneswood 25/04/05

Stoneswood 05/10/04

Stoneswood 19/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Stoneswood Oldham Road Delph Oldham OL3 5EB Lead Inspector Carol Makin Unannounced Inspection 29th September 2005 10.10a 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 Stoneswood DS0000005522.V249336.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. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stoneswood Address Oldham Road Delph Oldham OL3 5EB 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) 01457874300 NO FAX Northern Care Homes Limited Care Home 28 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (18), of places Sensory Impairment over 65 years of age (2) Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 18 OP up to 8 DE(E) and up to 2 SI (E) Date of last inspection 25th April 2005 Brief Description of the Service: Stoneswood is a residential care home providing personal care and accommodation for up to 28 older people. It is owned by Northern Care Homes Limited, which is a private company. The home, which is a large Victorian building, stands in its own grounds in a semi-rural location on the outskirts of Delph, and approximately six miles from Oldham Town Centre. There is a public transport link to Oldham. The home provides 22 single and three double bedrooms. The proprietors have chosen to use the double rooms as singles, and use the remaining three registered places for day care. Accommodation for residents is provided on the ground and first floors of the building, with a passenger lift for ease of access. The basement area is used for storage and utility rooms. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 29th September 2005. Action had been taken in relation to many of the requirements, which were made as a result of previous inspections. Some had been fully addressed, but others required further improvement to meet the National Minimum Standards and the Regulations, and there were others for which no action had been taken. The inspector spoke with some of the residents, the manager, and the administrator, carried out a partial inspection of the premises, and examined records. Verbal feedback of the findings of the inspection was given to the manager, during, and at the end of the inspection. The manager who was in post at the last inspection, had recently left and a new manager, Michelle Jacques had been in post since 12th September 2005. Mrs Jacques was in the process of submitting an application for registration to the Commission for Social Care Inspection at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 6 Residents said that the need for more activities continued to be an issue. Care plans need to be improved, and residents must be involved in drawing them up. A record must be kept of complaints made to the home. Support systems for staff need to be improved. A system must be set up for monitoring the quality of the service provided at the home. The owners need to provide business and financial plans, and must demonstrate that the necessary insurance cover is in place at all times. 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. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 the following standard(s): The standards in this section were not assessed on this inspection. EVIDENCE: Standard 3 was met at the last inspection and was not reassessed on this occasion. Intermediate care is not offered at Stoneswood. Standard 6 is therefore not applicable. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 Care plans did not fully identify the needs of the residents, leading to the potential risk that health care needs may not be met. Risk assessments were not completed for residents who deal with their own medication. Residents felt that they were treated with respect and their dignity was maintained. EVIDENCE: A sample of resident’s care files were inspected. Care plans contained some good detailed information, but the care plan on one file seen had not been fully completed, and there was no indication that it had been reviewed since it was completed in July 2005. Another file seen had a fully completed care plan and it had been reviewed in September 2005. All care plans and risk assessments must be reviewed every month, or more frequently to meet resident’s changing needs, and records must demonstrate that this has been done. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 10 Records showed that residents had been weighed on 8/9/05, and the manager said that she had arranged to share the use of the ‘chair’ scales with the company’s other home so that residents can be weighed every month. Residents also need to be weighed on admission to the home, and receive nutritional screening, which is subsequently monitored, together with weight gain or loss. The manager said that they had recently changed to a different monitored dosage medication system, and the 7 members of staff responsible for medication had received training from the pharmacy concerned on 21/9/05. Medicine records which were checked, were found to be in order with one exception, i.e. risk assessments are required for residents who self medicate. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 the following standard(s): 12 Activities were not sufficient to suit resident’s preferences and capacities, and provide them with enough stimulation. EVIDENCE: Standards 13,14,15, which were met at the last inspection were not reassessed on this occasion. Progress regarding the provision of activities in the home was reviewed as this was identified at the last inspection as needing improvement. The manager said that she had recently appointed an Activities Organiser, and it was hoped that she would begin work at Stoneswood towards the end of October (05). In addition to this the manager had arranged for a singer to entertain the residents on 28/09/05, and an outing to Failsworth Liberal Club for a potato pie supper on the night of the inspection, she was also linking up with the company’s other home to join in with some of their activities. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 12 On speaking to residents, they felt that there was still a need for more activities. Some residents enjoyed reading, and there was a selection of library books, some with large print, which were changed every 3 months. One gentleman enjoyed an early morning walk in the grounds of the home, reading his newspaper and doing the crosswords and word/number games. He also delivered newspapers to other residents. A lady who had very poor eyesight, said that she often closed her eyes and went to sleep because she couldn’t see to do anything. There was a mixed response to the entertainment provided by the singer the previous day. Two residents had chosen to go on the outing to the Liberal club that night. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 the following standard(s): 16,18 The home could not demonstrate that those making a complaint would know whether their complaint had been taken seriously and acted upon. Staff require further training to ensure that residents are protected from abuse. EVIDENCE: An appropriate complaints procedure was available, but a record of complaints made could not be found. Without this the home could not demonstrate that that complaints had been dealt with appropriately, and that those making a complaint had been informed of the action taken by the home, and the outcome of their complaint. In response to a requirement made previously, for staff to receive training in abuse and the protection of vulnerable adults, training courses had been arranged for 19/10/05, 16/11/05 and January 2006. The training is arranged in 3 groups to enable all staff to attend. The local authority and the home’s policy/ procedure documents in relation to these topics were also available for staff to read. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 the following standard(s): 19,21,23,24,25 The owners were maintaining the premises and grounds, and providing pleasant accommodation, for the people who live there. EVIDENCE: There had been some repainting of the building internally and externally since the last inspection. A new carpet had been fitted in the hall, but the repairs to the stair carpet had not been done. The manager said that the ground floor bathroom which is not suitable for residents because there is no hoist or other aids/equipment, is to be converted into an office. There is currently only one usable bathing facility for a registered number of 28 residents, which is way below the national minimum standards. The owner has, however, said that this will be addressed when an extension, for which they have received outline planning permission, is built on to the property. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 15 Residents were satisfied with their rooms, and they were able to bring in furniture and other personal possessions of their choice to meet their needs, and make the rooms homely. Valves to regulate the water temperature had been fitted to wash hand basins since the last inspection. The manager reported that the programme of enclosing radiators for safety reasons was continuing, with communal areas and first floor corridors still to be done. An assessment of pipework must be made to identify whether any pipes need to be enclosed to protect residents from injury. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 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): 27,28,30 The staffing levels within the home were sufficient to meet the needs of the residents. Overall, the training programme for staff was suitable for meeting the needs of the residents. EVIDENCE: The information, which was provided for inspection, indicated that staffing levels within the home met the standards, and were sufficient to meet the needs of the residents. The manager stated that 11 of the 18 care staff (61 ), employed at the home had achieved an NVQ 2 qualification. Details were provided about various training courses, which had been arranged for staff during October and November 2005. Training regarding dementia and challenging behaviour had been arranged with Oldham Social Services, but the manager was waiting for the dates. The proposed manager was beginning a 5 day course in relation to this topic on 3/10/05. As noted previously in this report, staff had received training in medication (Standard 9), since the last inspection, and training in relation to the Protection of Vulnerable Adults had been arranged, (standard 18). Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 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): 33,34,35,36,37,38 Business and financial plans are needed to demonstrate the financial viability of the home. The registered person must demonstrate that the legally required insurance cover is in place at all times. Supervision systems for staff need to be improved. Record keeping could be improved to safeguard resident’s rights, and more opportunities were needed for residents and other interested parties to comment on the running of the home. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 18 EVIDENCE: The proposed manager, Mrs Michelle Jacques, had been in post since 12th September 2005. Mrs Jacques had previously been the registered manager of another care home, and at the time of the inspection she was in the process of submitting an application for registration as the manager of Stoneswood, to the Commission for Social Care Inspection. The manager said that quality assurance and quality auditing systems were not in place, although monthly meetings for residents chaired by an advocate from Age Concern, were still in operation, and she had held a staff meeting since taking up the post on 12th September 2005. As on previous inspections, there were no business or financial plans, despite requirements having been made at all previous inspections. The certificate of insurance which was displayed in the home at the time of the last inspection, had expired on 17th July 2005. Records of money held in safekeeping for residents were selected at random for inspection and were found to be in order. The administrator said that 5 residents dealt with their own finances, and no items were held in safe keeping for residents at the time. The proposed manager reported that there was no formal supervision for staff, but she was in the process of setting up a system which is in line with the national minimum standards. A number of records were being maintained to a satisfactory standard. Action was, however, required to address deficiencies identified in some areas, which have been noted previously when reporting on compliance with other standards (e.g. 7,8,16,38). The proposed manager had set up a new fire log book, showing tests and checks of the fire alarm, means of escape, and fire extinguishers, having been done on 21/9/05. A certificate displayed in the home showed that fire training had been provided for staff by an external trainer on 9/2/05. The last recorded dates in previous fire precautions records were dated 19/5/05. The emergency lighting needs to be checked each month, and a fire drill needs to be carried out. Separate books were kept for recording residents accidents and staff accidents. The quality of recording needed to be improved. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 2 X 3 3 2 X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 1 3 1 2 2 Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 20 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 7,37 Regulation 15 Requirement The registered person must ensure that care plans are completed for all the assessed needs of residents, reviewed to meet the changing needs of resident and routinely, at least once a month, and that the resident or their advocate are involved in the process. The registered person must ensure that records are kept of residents’ weight and nutritional screening on admission to the home, subsequent monitoring, and investigations of any concerns regarding weight gain or loss. The registered person must ensure that a risk assessment is provided for all residents who self medicate. The registered person must ensure that a record is kept of all complaints made to the home. The registered person must ensure that the stair carpet is repaired/replaced to prevent tripping hazards. Timescale for action 21/10/05 2 8,37 12,13,14, 15 21/10/05 3 9 13 21/10/05 5 6 16 19,20 22, 17 (2) 13,16,23 21/10/05 30/11/05 Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 21 7 25,38 13,23 8 31 8,9,Regn Regs 2(3) The registered person must 31/01/06 ensure that, within a risk management framework, all radiators and areas of exposed pipe work are either guarded or fitted with guaranteed low temperature surfaces. The registered person must 31/10/05 ensure that an application for the registration of the manager is submitted to the Commission for Social Care Inspection. The registered person must ensure that business and financial plans are available for inspection. The registered person must demonstrate that the necessary insurance cover is in place at all times. The registered person must ensure that supervision is provided for staff in accordance with the national minimum standards. The registered person must ensure that a quality assurance and monitoring systems are provided in line with the National Minimum Standards. The registered person must ensure that the emergency lighting is checked each month, a fire drill is carried out, and records are kept of this. The registered person must ensure that the quality of recording in the accident book is improved. 21/10/05 9 34 25 10 34 25 21/12/05 11 36 18 01/12/05 12 33 24 31/01/06 13 38 23,17(2) 31/10/05 14 38 17 (2) Schedule 4 31/10/05 Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 22 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 12 Good Practice Recommendations The registered person should ensure that the provision of activities is increased to meet the needs of the residents, including those with specialist needs. Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Stoneswood DS0000005522.V249336.R01.S.doc Version 5.0 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. 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