Inspection on 10/12/07 for Stoneygate Ashlands II

This inspection was carried out on 10th December 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stoneygate Ashlands II 28/09/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Stoneygate Ashlands II Ratcliffe Road Leicester LE2 3TE Lead Inspector Linda Clarke Unannounced Inspection 10th December 2007 09:30 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 Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 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. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoneygate Ashlands II Address Ratcliffe Road Leicester LE2 3TE 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) 0116 2705678 Prime Life Ltd Mrs Diane Smith Care Home 37 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (37), Physical disability (37) of places Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP. Dementia - code DE. Physical Disability - Code PD. The maximum number of service users who can be accommodated is 37. Newly registered first. 2. Date of last inspection Brief Description of the Service: Stoneygate Ashlands II is a care home providing personal care and accommodation for up to thirty-seven persons who may have additional needs, which may include Dementia or a Physical Disability. The home is purpose built, and located within a residential area of Leicester. Car parking facilities are available to the front of the home. The home provides communal and bedroom facilities on both the ground and first floor. Access to the first floor is via a passenger lift. The ground floor has a central dining room, and provides two smaller lounge/dining rooms and a separate lounge for service users who wish to smoke. The first floor provides two lounge areas. All bedrooms are single and benefit from en-suite facilities, which include a toilet, wash hand basin and walk-in shower. Bathing facilities on each floor are also provided which are adapted to support the needs of people with impaired mobility. Stoneygate Ashlands has a landscaped area garden, which is accessible to service users, providing areas in which to walk along with Pergolas and outdoor seating. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 5 Information is located on site detailing the range of services offered, which includes the Statement of Purpose and Service User Guide. The fees as provided by Prime Life Limited being in the range of £276.00 - £455.00. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included reviewing the Registration Report, reviewing the Annual Quality Assurance Assessment (AQAA), which is a self-audit tool completed by the Registered Manager. We (Commission for Social Care Inspection) sent surveys to seventeen service users of which seven were completed and returned, sixteen were sent to care staff of which four were returned, in addition eight surveys to General Practitioners and two surveys to District Nurses were sent out of which one was turned. The unannounced site visit commenced on the 10th December 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Stoneygate Ashlands II. Four service users were selected and discussions were held with two of them. In addition two other service users were spoken with and discussions were held with a visiting District Nurse. Observations involving service user care and interaction between service users and staff were also noted. The Registered Manager was asked to approach visiting relatives when they visited to advise them that the Inspector was available should they wish to make any comments. No introductions were made to the Inspector from relatives. The Inspector did speak with one relative who came into the same area to which the Inspector was sitting. What the service does well: Stoneygate Ashlands II supplies information for prospective service users, which enables individuals and their relatives to have a good understanding of the services offered by the home, before visiting to have a look around. Detailed assessments of a prospective service users needs are undertaken by a senior member of staff, sometimes in conjunction with social care professionals. Stoneygate Ashlands II has an inclusive atmosphere with regards to service users relatives, which ensures relatives are kept informed as to the changing care needs of service users, relatives are encouraged to visit and are made to feel welcome. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 7 The Commission for Social Care Inspection (CSCI) sent out surveys to care staff when asked what the home does well the following comments were made: • The service supports all users and staff individually, respecting all aspects of service users needs. It offers free choice in what may be needed, and it cares and looks after all in the home. There is a good staff team and manager, and the home has a lovely friendly atmosphere, the service users are happy which is a priority. We offer indoor activities and trips out. We offer a selection of different foods. • What has improved since the last inspection? What they could do better: Records need to be put into place which evidences that service users receive a copy of their contract which outlines their terms and conditions of occupancy. Care plans could be improved, if written from the prospective of the service user, and include detailed information on preferred daily routines, which is of particular benefit to those service users who cannot communicate effectively due to their health. Service users privacy and dignity needs to be promoted and maintained, this can only be achieved by improving the care service users receive throughout the day and by ensuring staff are proactive in recognising and understanding the needs of individual service users. Day to day management of the home needs to be proactive, through the deployment of staff to ensure that service users individual changing needs, do not impact on the care and attention fellow service users receive. Systems need to be put into place where by regular checks are carried out to ensure that medication records accurately reflect how medication is dispensed and administered. Please contact the provider for advice of actions taken in response to this Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 9 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 Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable, as the service does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information about the service and can be confident that their needs will be assessed. EVIDENCE: Prospective service users and their relatives are provided with information as to the services provided by Stoneygate Ashlands II documentation includes the Statement of Purpose and Service User Guide, which detail the aims, objectives and philosophy of care of the home, the terms and conditions of occupancy, information about staff including their experience, training and qualifications. Supportive documentation is also available, and includes information on how to raise concerns, accommodation, and catering and social opportunities. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 11 Information supplied in the AQAA (self assessment tool) advised that the Statement of Purpose and Service User Guide are available in different languages and formats upon request. Additionally Prime Life Ltd., to which Stoneygate Ashlands II is part of, supplied a copy of policies and procedures, which outline how the admission of service users including their assessment is managed. Information detailed within the AQAA states that service users are provided with a contract detailing their terms and conditions of occupancy including and any additional charges. The records of the four service users whose records were viewed did not contain a copy of their contract, the Registered Manager advised that the Head Office of Prime Life Limited retains a copy. Service users who completed and returned their surveys, in some instances did not answer the question as to whether they had received a contract, those that answered said they had a contract. The Registered Manager needs to evidence that service users have a contract. The CSCI sent out surveys to service users as part of the Key Inspection process, comment cards confirmed that service users were provided with sufficient information about the home before moving in. The four service user records included an assessment of need, the assessments being undertaken prior to the individual moving in, which ensures that the needs of the person can be met. Assessments are undertaken by the Registered Manager and Senior Carer, where service users are funded by Social Services an assessment is also undertaken by a Social Worker. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst service users health care needs are met, their privacy, dignity and personal care could be improved. EVIDENCE: The care plans of four service users living at Stoneygate Ashlands II were looked at, the care plans were individual to the needs of the service user, and recorded specific areas of care and support needed. The care plan focused on all aspects of the individuals’ life and included physical health and well-being, mobility, mental health and well being. The care plan records the services to be provided. Care plans had been regularly reviewed, and were supported by a daily record of information written by the staff responsible for the delivery of personal care. Care plans could further be improved through a person centred approach, which details how the service user wishes to be cared for in all aspects of their Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 13 daily lives, and information as to service users preferred daily routines; this is particularly relevant where service users due to their health are unable to express their views. A representative of Prime Life Limited, who visited during the afternoon of the site visit, brought a template of a new style of care plan, which is to be used, and is reported to have been designed to reflect a person centred approach. Observations of a small group of service users, during the late morning, lunchtime and early afternoon took place, all being seated in a small lounge/dining room identified that in some instances service users individual care and the promotion of their dignity is not always maximised and maintained. Observations of service users well-being was discussed with the Registered Manager, and explanations sought as to why a service user had not had their clothes changed after breakfast. The Registered Manager said that the service user had declined to change their clothing, however the individual’s top clothing had been changed. The changing of the service users clothing had been undertaken in the lounge, further compromising their dignity. It was also noted that the service user remained in their wheelchair, which had remnants of their breakfast contained within, and remained at the dining table after breakfast and staying there until they had eaten lunch, which was a period in excess three hours. Staff also acknowledged that service users in some instances whilst sitting in their wheelchair did not have the appropriate pressure relieving equipment in place. Observations in the afternoon, of the same group of service users noted staff were attentive to service users needs, and ensured their comfort. Staff offered service users choice as to where they sat, and ensured that pressure relieving cushions were in place. Service users were asked as to their views of the care they receive and the approach of staff, comments were in the main complimentary, however some comments identified shortfalls in staff attitude and approach to care. One service user said that staff were very attentive and helped them to maximise their independence, and had a good understanding of their needs, and that staff were available when they were needed. The service user went onto say that staff were cheerful, and were confident in using the specialist equipment required. A service user said that staff had a ‘cheerful disposition’, but said that a minority of staff are ‘a little temperamental’, when they (the service user) ‘are not quick enough’. Another service user said that staff made them laugh, and they were always happy, with the exception of one member of staff who did not speak to them. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 14 A service user said that staff on one occasion a few days ago they had had their trolley (walking aid which included storage space) taken away from them for a period of time, and had received no explanation for this. The Registered Manager was advised as to service users comments. Daily records and care plans evidenced that service users access health care professionals as and when needed, one relative spoken with said that they were kept informed as to the health of their parent, and were confident in the knowledge and abilities of the staff. A District Nurse who was visiting on the day of the site visit, said that they had noticed significant improvements to the care service users receive, following training provided by the District Nurse team to care staff, which covered catheterisation, dry dressings and skin care. The District Nurse went onto say that staff are ‘very good and understanding of service users’, and that staff contact the District Nurse team appropriately. The District Nurse said that staff follow their instructions on service user care, and record the care they deliver. Medication and medication records of two service users were looked at, it was noted that for one service user, there was an absence of a signature for one service users tablet for an evening. The Registered Manager checked, and was confident that the medication had been administered, but the records had not been signed to record the event. It was also noted that the medication for two service users is dispensed at teatime, for them to take later in the evening, as per the wishes of service users. Staff administering the medication sign the record sheet, which is a record stating the medication has been administered, when it fact in these instances it has been dispensed. It was suggested to the Registered Manager that the service users care plans reflects the choices service users have made. The Registered Manager confirmed this would be acted upon the following day. Service users have in some instances elected to have a telephone in there own room, the Registered Manager confirmed that telephone lines were installed to all rooms, and that they were awaiting the telephone company to activate the lines. Service user care plans where service users have expressed any views or opinions record how they wish to be supported during illness and death, including arrangements following their death. All of the surveys received from service users indicated that staff and listen and act upon what they say, and confirm that they receive the medical support they need. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 15 Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users make choices about daily living; with choices offered as to activities and meals, service user independence, care and dignity is not in all instances maintained. EVIDENCE: Service users were asked about activities, a majority indicated that there are some activities, but that in the main they choose not to participate, one service user said they do however enjoy the bus trips. Service users in surveys sent out to them by the CSCI confirmed that the home provides activities but gave conflicting answers as to whether they participate. Staff on the day of the site visit were putting up Christmas decorations and Christmas Trees, and encouraged service users to participate. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 17 The Registered Manager confirmed that service users had recently been consulted to establish their views as to activities and recreational events and meals, following comments raised by some service users. The results of the surveys had resulted in a change of approach with regards to how activities are organised, in that activities are now more ad-hoc, and not timetabled too much in advance. Information with regards to service users hobbies and interests is ascertained at the point of their moving into the home, which provides staff with information as to the service users life history and significant events. The care plan of one service user reflected that prior to a life changing event they had enjoyed playing pool, snooker and darts, the service user confirmed that these interests had not be pursued since his admission into care. The development of person centred care plans and discussions with service users should promote opportunities for service users to continue to participate in their hobbies and interests. A service user had a games consul in their room and said they very much enjoyed their own company and playing their games. The service user said that they attended a day care facility three days a week, and that transport was provided. All lounge areas have a large flat screen television, which is mounted on the wall, and can be viewed, from all areas within the lounge. Televisions were on in a majority of the lounges; the number of lounges provides service users with a choice as to which channel they wish to watch. Service user surveys sent out by the CSCI gave mixed responses as to whether they enjoyed the meals, however the majority indicated they do like the meals. The Registered Manager confirmed that a service user had made a complaint about the food during their review, and that a representative of Social Services had investigated the complaint, and that the outcome was awaited. One service user said that they assisted with meal preparation and had attained a Food Hygiene Certificate, which they very much enjoyed. We spent time with a small group of service users during the lunchtime meal. Service users were given a choice for the three courses of the meal. It was noted that three service users, two of which were seated in a wheelchair were very low with regards to their seating position and the height of the table, this impaired their ability and comfort with regards to eating their meal. Service users were not supported during their meal, which staff and the Registered Manager said usually would occur, however the needs of another service user had prevented this. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Stoneygate Ashlands II has a Procedure for handling Concerns, Comment & Complaints; this is provided to all service users and their relatives upon their moving into the home, additionally a copy of the Procedure is displayed. The Registered Manager confirmed that a service user with regards to the quality of the meals has raised one concern, and that a representative of Social Services, as part of the investigation had visited the home and participated in a meal with the service users. The Registered Manager is awaiting the outcome. Service users within their surveys sent out by the CSCI indicated that they know who to speak with if they were unhappy, and how to make a complaint. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 19 Stoneygate Ashlands II has a Prevention/Detection of Abuse Policy and Procedure, which outlines the responsibilities of the individual and organisations in responding to or alerting to possible abuse. Two members of staff were spoken with and were able to outline their roles and responsibilities. Discussions with staff and information viewed confirmed that staff receive training on how issues of concern regarding potential abuse are reported. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Stoneygate Ashlands II is a purpose built care home, and complies with the Disability Discrimination Act, with all areas being accessible for people who use a wheelchair. There are four lounge areas (where eating can also take place); and one larger dining room. One lounge is designated for those service users who wish to smoke, and is well ventilated. The lounges have a mixture of settees and high back chairs. All communal furnishings are of a good quality. There are communal toilet facilities on each floor, and are close to the lounge areas. All bedrooms have good-sized en-suite facilities, which include a toilet, Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 21 wash hand basin and walk-in shower area. There is a bathing facility on each floor – both are adapted to support the needs of people with impaired mobility. All areas of the home are accessible to service users to maximise independence. There is a lift to the first floor; and grab rails, in corridors and bathrooms and toilets. Loop systems have been installed in all lounge areas, which has benefits to those service users with a hearing impairment, and televisions are connected to walls to make it easier for service users to see them. The lounges are smaller in size to create a homely atmosphere. All bedrooms provide more space than the minimum 12 square metres as defined in the National Minimum Standards, and there are no shared bedroom facilities. All bedrooms have good quality furniture with adjustable beds for service users who require them. The flooring throughout the home is a mixture of carpets and vinyl promoting cleanliness and ease of movement particularly for those service users who have impaired mobility. There is a good amount of natural light in all rooms. The heating has been designed to ensure that the pipes are hidden which promotes the safety of service users; and all radiators are thermostatically controlled to ensure a low surface temperature. One service user with a physical disability spoke positively of the support they receive, stating that staff are aware of their needs, and have a good understanding of how to use specialised equipment which maximises their independence and choice. The service user went onto say, that the floor coverings in the home, and the wide door ways make it easier for them to move about the home independently in their wheelchair. All service users spoken with had transferred from the original Stoneygate Ashlands II in to the new purpose built accommodation, were complimentary about the facilities, and were particularly pleased with having an en-suite facility. Service users said they had chosen their bedrooms and had contributed to the colour scheme. Service users in some instances had personalised their rooms with furniture, pictures and ornaments. A garden area surrounds the home, which is accessible to service users who require the use of a wheelchair and have impaired mobility. There are Pergolas and seating areas provided. There is a laundry area for the washing of service users clothing, and Policies and Procedures outline staff responsibility in ensuring that service users are Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 22 protected from communicable diseases and infections, on the day of the site visit staff were observed wearing disposal gloves and aprons as required. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust recruitment process protects Service users; staffing levels in some instances do not ensure service users needs are always met. EVIDENCE: The Registered Manager stated that staffing levels had increased by an extra care staff on duty throughout the day, since the opening of the home, this had come about following a revision of staffing levels, to ensure their were sufficient staff to attend to service users given the layout and number of communal facilities. Service users in one lounge and dining area did not receive the support they required at their lunchtime meal due to the needs of another service user, the Registered Manager must ensure that that there is flexibility in staffing levels to ensure service users needs are met. Staff surveys, which were completed and returned, indicated that staff in the main felt there were sufficient staff to meet the needs of service users. Information supplied by the Registered Manager in the AQAA states that 71 of staff have attained a National Vocational Qualification in Care. Staff Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 24 indicated in their surveys that they receive the training relevant to the care needs of service users. Observations in some instances indicate that training is not being reflected in the care service users receive. The staff records of two members of staff recently recruited were viewed, all were found to contain information required for the employment of staff, which included a completed application form, two references and a Criminal Record Bureau (CRB) disclosure. Staff surveys sent out by the CSCI also evidence that staff had undergone a robust recruitment process. The recruitment process is overseen by the Prime Life Human Resource Department, and is supported by Policies and Procedures, and includes random audits of staff files held by the home by the relevant Department. Staff spoken with said they had received training relevant to the health, safety and welfare of service users, which included First Aid, Fire Awareness, Moving and Handling and Hoist Awareness. In addition staff said they had received training reflective of the needs of service users, which included a course in Dementia Awareness, which is a modular course run by a Leicester College, lasting over several weeks. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home with good leadership, ensuring that service users health, safety and welfare are promoted. EVIDENCE: The Registered Manager, Mrs Diane Smith transferred from the original Stoneygate Ashlands, along with her staff team, which promoted the continuity of care for service users, who moved into the new home. The Registered Manager has attained a National Vocational Qualification (NVQ) at level 4 along with the Registered Managers Award. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 26 A quality assurance audit has not as yet taken place in the home, due its recently being opened; the Registered Manager was unable to advise as to when the audit would take place. Service user views have been sought with regards to activities and meals, and the findings have been used to make changes to both aspects of the home. The Registered Manager confirmed that service user and staff meetings take place on a regular basis, with minutes being kept. Staff also benefit from receiving regular supervisions which were either observational, whereby a Senior carer worked alongside them to review their work practices, or alternatively supervisions take place on a one to one basis, which take the form of a discussion as to the staff training needs, and review of care practices. A record of supervision and annual appraisals is kept. The financial records of one service user whose records were viewed were checked, the home manages ‘spending money’ for the service user, and regular audits of financial transactions are kept, and were checked on the day of the site visit and found to be in good order. Individual service user care plans record how service user finances are managed, and who is responsible. Information supplied by the Registered Manager in the AQAA and the contents of the Registration Report of the service confirms that the home meets the requirements of all regulatory departments, which include Fire and Environmental Health. The AQAA confirms that systems including fire, central heating and emergency calls systems are regularly checked. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 27 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 4 3 4 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A 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 The Registered Manager to ensure that the recording medication administration is properly maintained and reflects a true account of events. The Registered Manager to ensure that the personal care service users receive is consistent and is of a high quality, which promotes their dignity at all times. The Registered Manager to ensure that service users individual and collective needs are met at mealtimes. Timescale for action 10/01/08 2 OP10 12(4) 10/01/08 2 OP15 18(1) 10/01/08 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 OP2 Good Practice Recommendations The Registered Manager to establish a system that evidences that service users receive a copy of their DS0000070206.V355317.R01.S.doc Version 5.2 Page 29 Stoneygate Ashlands II contract detailing the terms and conditions of occupancy. Stoneygate Ashlands II DS0000070206.V355317.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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