Inspection on 05/12/06 for Stroud House

This inspection was carried out on 5th December 2006.

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

Stroud House 24/04/07

Stroud House 07/11/05

Stroud House 12/05/05

Stroud House 21/01/05

Stroud House 21/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Stroud House Rothercombe Lane Stroud Petersfield Hampshire GU32 3PQ Lead Inspector Val Sevier Unannounced Inspection 5th December 2006 10:00 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 Stroud House DS0000032866.V319144.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. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stroud House Address Rothercombe Lane Stroud Petersfield Hampshire GU32 3PQ 01730 262657 01730 260689 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) Western Health Care Limited Mrs Irene Patricia Morton Care Home 25 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (25), Physical disability over 65 years of age (6) Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A total of 12 service users may be admitted in the categories MD (E) & DE (E) at any one time. 7th November 2005 Date of last inspection Brief Description of the Service: Stroud House is a large house on the main road through the village of Stroud, near to Petersfield. The home is registered for up to twenty-five older people, some of who may have dementia, mental disorders and/or physical disabilities. Accommodation is provided by fifteen single and five double rooms for people who have chosen to share a room with each other. The fees for the home are based on assessed need and range between £385 and £575. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 5th December 2006 during which there were discussions with staff, residents, relatives and visitors to the home. In addition 5 relatives had completed questionnaires prior to the visit. During the visit to the home a tour of the premises was carried out with where possible, permission of the residents at the home, this also included their rooms. Staff and care records were sampled and in addition to speaking with staff and residents, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘expert by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. On this occasion the inspector was accompanied for part of the visit by an ‘expert by experience’ Tina Coldham, who spoke with some of the residents at the home about their experiences and who carried out a partial tour of the home. Tina’s observations and comments have been included in this report where she is referred to as expert by experience. Tina’s summary was “Residents seemed quite happy and well served by caring staff in a nice environment which encouraged activities and interest.” What the service does well: The residents are encouraged to be part of the home, to carry out tasks as if it were their own home such as laying the tables, finding out what others would like for lunch or supper. With use of a driver and minibus the residents have access to the community for shopping or other activities. The expert by experience spoke with several residents at the home and was able to observe staff and resident interactions. “There seemed to be a nice Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 6 rapport between certain staff and residents. The residents seemed to get on with one another, chatting at the dining table to a limited extent depending on their capacity to do so.” What has improved since the last inspection? What they could do better: The areas in which improvement and action are needed are as follows: Assessment of residents needs prior to and after admission and the care planning of action staff must take to meet those needs. The residents must be protected by the home’s policies and procedures in dealing with medicines; this includes records of giving medicines, storage and use of Oxygen. A letter of concern regarding administration and storage of medication was sent to the home after the inspection and the home has responded and taken appropriate action. There was evidence that residents are at risk and not protected through a thorough recruitment process. This was of concern at the last inspection. Personal medication such as creams should not be left in communal bathrooms or toilets. The downstairs bathroom was cluttered with drying washing, cleaning equipment and staff belongings; which could be hazardous to both residents and staff. The residents must be protected by regular checks on equipment that is there for protection such as fire alarms and equipment. Please contact the provider for advice of actions taken in response to this Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 7 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. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 & 3 (standard 6 is not applicable at this home) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of consistency in carrying out assessment of residents prior to moving to the home, placing some individuals at risk of being accommodated and then not meeting their care needs. EVIDENCE: A prospective family visited the home whilst the inspector was at there; the general manager assisted the visitors and gave them a copy of the statement of purpose for the home. The inspector was able to see the document also. It still has the name of the previous regulatory body the National Care Standards Commission as the body that the home is registered with. The document does give adequate information that can be used to make an informed decision. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 10 The inspector viewed three pre admission assessments of individuals who had moved to the home since the last inspection. Of these one had been completed fully, one partially and for there third there was no evidence that an assessment had been carried out and this individuals care plan there was no evidence what needs were being met. This individual was followed thorough on other records at the home and it was evident that there was high level of support needed. The document itself is comprehensive and where it was completed gave a full picture of the needs of the individual, which were then carried through to care plans. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet resident’s needs, including those receiving palliative care. The recording of the administration of medication is poor and potentially places residents at risk. EVIDENCE: The inspector viewed three care plans related to the pre admission assessments. Where the assessment had been competed there was evidence that care planning had followed on with action for staff to follow to assist in meeting needs. The care plans included a falls chart and falls risk assessment. The care plans had been reviewed every three months and are due to be reviewed in January 2007. The general manager said that the plans were reviewed there monthly for all residents unless needs changed. Where the Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 12 residents had had a partial pre admission assessment there was evidence that care plans were in place with individual risk assessments associated with a physical illness that can cause falls. The third care plan seen for an individual who moved to the home in June 2006, was incomplete with a pen picture in place with some information on needs, but the care plans in the file were blank. The findings were discussed with the general manager at the time. There was evidence that staff had completed daily notes on the three residents and action they had carried out such as calling a doctor with outcomes from the visit. One individual’s notes indicated that staff had given a suppository. The inspector asked whether competency had been assessed for staff to carry out this procedure. The general manager stated that the District Nurse had given staff training which staff confirmed, however there was no record evident of the training or competence. There was a record in the daily notes for the individuals with no care plans, which indicated that their physical health had declined with records saying that the individual had not eaten for 4 days and had a sore mouth on 3/12/06. There was a record that the GP had visited on the 4/12/06 and that the GP had indicated that tender loving care was needed. There was no record of how this care would be given. All three care plans indicated that emergency care would be given ‘depending on the quality of life’. As there was no evidence of how these issues would be evaluated this was discussed with the general manager who suggested that any decisions would involve the family and GP, however this was not evident in the document. One resident had monitoring forms that indicated that their general health with regards to weight, blood pressure pulse and blood sugar was carried out monthly, however the last record was September 2006. Since the inspection the registered provider has informed the inspector that monitoring had been carried out however the records had not been transferred to the care plans seen at the inspection. The care plans are kept in a cupboard, which also contains the medication stock, a small controlled drugs cupboard, clinical waste bottle and syringes. The cupboard contained OraMorph (500mls and approximately 100 mls of another 500mls). The Controlled Drug (CD) book (a hard back writing book), was numbered and had entries for individuals for one individual who was prescribed Temazepam, one person was prescribed ‘Morphine patches’ of varying strengths, and another MST tablets. The instruction for the OraMorph for staff was that the individual could be given 20 – 40 mls 1-2 hourly for pain. This was in addition to the Fentanyl patches and Ibuprofen. Staff had recorded with two signatures on the MAR sheets when it had been given, and this seemed to be when they assisted the person to move from the bed first thing in the morning, the senior staff said that it was given half an hour before assistance was given to ease that discomfort. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 13 The inspector looked at the individuals care plan, (in addition to the three already seen), and noted that there was no care plan to advise staff of this. There was no administration record on the MAR sheets of the staff changing the Fentanyl patches, although they had signed in their ‘CD’ book. The home has been advised to refer to guidelines on how they should record in the CD book. There were three strengths of the patches in the cupboard, when looking at the MAR charts it was not clear which were being used, after discussion with the senior staff at the home, it was apparent that the stronger one was being used, this was audited through the daily notes. Since the inspection the registered provider has confirmed to the inspector that the pain management needs of the individual were variable and the GP was aware of the various strengths of pain relief that were available, which supported the home in assisting the individual to be comfortable. When looking at the MAR charts it was noted that an individual was prescribed Nitrazepam, which was not being treated as a CD. There was no indication when an ‘as required’ medication had been given as to the reason and effect. For one individual, who had been prescribed Movicol 2 daily, for the 30 days preceding the inspection, there was no evidence that this medication had been given. In addition there were 41 gaps where there was no record of a prescribed medication having been administered, or reasons as to it being withheld. There are care supervisors at the home who have received training in administration of medication. There is a monthly rota that indicated that there are usually six different staff administering medication on a daily basis. It was noted that one resident had a ‘beware of oxygen’ notice on their bedroom door. Staff seemed uncertain whether the individual still needed it. There was no mask observed to be in the vicinity. The cylinder was standing by the radiator. The inspector viewed the Regulation 37 notices that the home had sent to CSCI a book is kept at the home to record incidents such as falls. Book 5 was in use, on the wall and had 27 records in it from 3/10/06 to 2/12/06 this was double the number of incident records sent to the CSCI. Many of these records stated that a resident had been found on the floor, no explanations as to how it occurred (resident often didn’t know themselves), not all were without injury. One record, which is of concern stated: ‘skin flaps were found on both legs, query due to catheter straps being pulled down the leg’. The injury and the possible manner in which it came about were raised with the general manager. Since the inspection the registered provider has informed the inspector that action was taken after the incident to minimise risks as far as possible. The expert by experience spoke with several residents at the home and was able to observe staff and resident interactions. “There seemed to be a nice Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 14 rapport between certain staff and residents. The residents seemed to get on with one another, chatting at the dining table to a limited extent depending on their capacity to do so.” Residents spoken with said that their needs were met and they had no requests for anything different. The external activities worker who was at the home at the time of the visit, stated that she saw staff in the home respond positively to resident’s requests, for example a cup of tea. Staff were observed offering residents help with getting up from chairs, with drinks and clothing. An advocacy service was advertised on the resident’s notice board. This was also present in the Managers office. There was a resident’s bill of rights and other resident policies displayed in the main thoroughfare. Residents spoken with did not voice any concerns or worries, except one lady who was complaining about someone who the expert by experience observed was a fictitious person (a man which wasn’t the chef, the only man present). The staff handled her anxieties well with distractions and care. Residents were taken to the toilet if needed, or were prompted nicely, i.e. before the trip out that afternoon. Care staff were seen to work at the residents pace. The staff gave people time to eat their meals at their own pace. Those requiring assistance were given that and others were encouraged to eat or have a choice in post dinner drink – hot and/or cold. Residents were spoken to politely and in a friendly manner by staff. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents receive good support, to full fill leisure activities, which are based on their individual abilities and aspirations. Personal support is offered in a way that promotes and protects resident choice. The meals in the home are good offering choice and variety. EVIDENCE: The expert by experience took the opportunity to speak with an external activities worker, who attends the home regularly for an hour to do various activities with residents. She has worked in this job for 4 months and felt that the home was ‘one of the better ones’. She observed that some ladies liked to help lay the table for instance and that they therefore had a role. The residents were supported in this activity by the staff. Two residents spoken with said they could go into the garden when they wanted, and they felt that they had freedom of movement and enjoyed sitting out in the summer. The notice board had a months worth of events listed Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 16 which showed a range of activities in and out of the home, outings, gym visits, yoga, massage sessions, and hairdressing. There are 2 newspapers (a tabloid and a broadsheet) delivered to the home for anyone to read. There are plenty of books and films for TV that can be watched, present in communal areas. The garden had seating and flower beds, although sparse this time of year. The home has two ‘budgies’; one belonged to a resident who bought it in with her. Lunch was served with light music in the background, which was commented favourably by some residents. There were small flower arrangements on the dining tables, which seemed a nice touch. One residents spoken with said the minibus driver was one of the nicest men she had ever known. Others within earshot appeared to agree. “He is helpful when going out on trips.” Residents said they could go out into Petersfield if they requested this. The local Roman Catholic priest takes communion on a Wednesday. The residents said they could go to the local church if they wanted. Charging for particular services was on the notice board, for example the rates for the hairdresser, chiropodist. A teacher and some school children visited for a specific Duke of Edinburgh award scheme. They engaged in conversation with some residents who seemed to enjoy the attention. The residents told the expert by experience that they have regular visits from nearby school. On the day of the visit many residents were encouraged to go out on a trip to Chichester Cathedral to listen to carols. Residents were brought their coats and told to wrap up warm for that place; this all happened at a pace that residents seemed comfortable with. One resident was seen helping to clear away another residents cup and saucer, another later in the day went round the home asking what people would like for supper. Residents said the food and the amount given was satisfactory. The menu was varied and appeared tasty, varied and wholesome. The staff also ate the same meals plated up for them as that served to residents. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 17 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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements to protect residents from harm or abuse are satisfactory. The information enabling individuals to complain is clear and readily available. EVIDENCE: There have been no complaints or allegations made since the last inspection to either the home or to CSCI. Relatives spoken with and those who returned comment cards were aware of how to complain and said they felt comfortable in speaking with the manager or staff on duty about any issues. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is suitable; however there are some areas that are cramped and décor looks tired and in need of decoration. EVIDENCE: The expert by experience undertook a partial tour of the home, which was followed by the inspector walking about the home in the afternoon. The bathrooms were noted to be clean and functional however, they appeared in need of some attention with painting. The downstairs bathroom is also used as a staff changing room and had staff clothes, bags, laundry drying (as the laundry is being upgraded) and a vacuum cleaner. Two pots of cream for which had been prescribed for named individuals were found in communal bathrooms. This could indicate communal use. The inspector was told that this bathroom is used for residents as it has a bath hoist. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 19 The lounge by the dining room had a variety of furniture, which offered a choice although the number of chairs could pose difficulties for those who needed support with their mobility. The other 2 lounges were not used whilst the inspector and expert by experience were at the home. Residents had their own rooms with locks on the doors so they can shut the door behind them. The door therefore can only be opened by key from the outside. The rooms had residents names clearly marked on the doors. The upper floor had 2 residents to a room, which appeared somewhat cramped. One resident was being cared for in bed in a double room, the individual had no way of calling for help, except by doing just that, which would be unheard if staff are all downstairs. During the walk about by the expert by experience she observed the individual calling for assistance and had to go downstairs for staff support. The resident did have music on in her room to soothe her. When the inspector walked round it was noted that in another double room there was only one call bell, which was situated on the far side of the room. One of the residents whose room it was came into the room whilst the inspector was there and the inspector asked about the call bell. The resident said: herself and the other resident “have known each other for ages and if she needs anything then I can use the call bell to get help’” The communal areas had a homely feel with plants and pictures around. Residents had individualised their rooms with their personal effects. Overall the home seemed clean and tidy with evidence of staff cleaning spillages around the home with a variety of equipment. Some corridors are rather narrow which may pose issues for residents who need support with mobility; one toilet is very small to manoeuvre in for those that need support. There was a general feeling of being cramped throughout the home, particularly with 2 residents sharing a room. The home has no spare space; this was evidenced by lack of storage space for personal hygiene equipment; staff clothing and records such as care plans being kept with medication. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to maintain and improve their quality of life. Since the last inspection the recruitment practices have not improved, with not all appropriate checks being carried out potentially leaving residents at risk. EVIDENCE: With the exception of the care plans, the small office is used to keep other records and staff information. It was noted that a list of staff names, addresses and phone numbers was taped to the side of a filing cabinet for anyone to see. The rota indicated that there are 4 staff on in between 7.30am and 2.00pm. In the afternoon/evening between 2.00pm and 9pm there are 2 staff, 2.00pm and 7.00pm there is another carer and between 4.00pm and 9.00pm another carer; there are two staff awake at nights. The care staff are supported by a cook and a domestic. In addition to caring and supporting the residents the staff do the laundry. The inspector sampled staff files of staff that are new to the home. It was found of the three seen two had evidence of recruitment checks. There was no Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 21 evidence on the third file that a relevant and up to date CRB or a check of Protection of Vulnerable Adults list (POVA), had been obtained. Fire training has been carried out twice in the past twelve months. Staff had received training to use the new hoists from the hoist company in November 2006. The general manager explained that Manual Handling training is planned for the New Year along with, medication training and dementia care. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are areas, which need improving as with a lack of management they are potentially placing residents at risk; these include areas of care planning, recording and health and safety. EVIDENCE: The registered manager was on leave on the day of the visit. A care supervisor and the general manager assisted the inspector throughout the visit. The inspector also met with the owner Mr Rogers. The local fire authority attended the home (June 2006) to speak to senior staff about the changes in fire risk assessment that became active on the 1st Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 23 October 2006. They have viewed the fire risk assessment and have said that it is satisfactory. The fire records were seen and it was noted that regular checks have been carried out i.e. weekly for fire alarms and emergency lighting – monthly, however the last recorded checks were noted as being the 29th October 2006. The lack of recruitment checks, insufficient care panning and recording and administration of medication contribute to the evidence that the management of the service needs to improve. The general manager stated that no personal monies are kept at the home with the exception of an amenity fund, which is supported by donations and money raised through fund raining events. The registered provider has advised the inspector that a questionnaire is issued periodically to visitors to the home to obtain their views however there was no evidence to support that these views are then evaluated. It was noted that the homes equipment was maintained and there were certificates to support this. Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 24 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 2 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 1 Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Sch 3 (1)(a) Requirement The registered provider must ensure that all prospective residents have a full needs assessment and that this is reviewed when needs change. The registered provider must ensure that care plans provide clear guidance to enable staff to consistently meet the care needs of residents. The registered provider must ensure that all physical health needs are addressed and if necessary professional support should be obtained. The registered person must risk assess the storage facilities of medication and care plans and take action as needed The registered person must ensure that medication administration records are kept, detailing what medication has been administered and any reasons why it may not have been given. The registered person must ensure that all needs are documented with action to be DS0000032866.V319144.R01.S.doc Timescale for action 14/02/07 2 OP7 15 (1)(2)(b) (c) 12 (1) 14/02/07 3 OP8 14/02/07 4 OP9 12(1), 13 (2) 18(1) (c) 12(1), 13 (2) 18(1) (c) 01/01/07 5 OP9 01/01/07 6 OP11 15 (2)(b)(c) 01/01/07 Stroud House Version 5.2 Page 26 7 OP19 23 (2) 8 OP21 23 (2) 9 OP29 19 Sch 2(7) 10 OP38 23 (2)(l) 11 OP38 23 (4) (a)(b)(c) taken for those where palliative care is to be given. The registered provider must ensure that residents have risk assessments with regards to summoning assistance and action taken as identified. The registered provider must ensure that residents have safe access to their choice of bathroom facilities. The registered person must ensure that staff are employed in the home only once a POVA First and a satisfactory CRB check has been obtained. This is a repeated requirement of 07/11/05. The registered provider must make suitable provision for storage at the home under a risk assessment framework. The registered provider must ensure that fire equipment is checked regularly and that records are maintained. 14/02/07 14/02/07 31/01/07 14/02/07 14/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Stroud House DS0000032866.V319144.R01.S.doc Version 5.2 Page 28 - 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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