CARE HOMES FOR OLDER PEOPLE
Stubby Leas Nursing Home Fisherwick Road Whittington Lichfield, Staffordshire WS13 8PT Lead Inspector
Sue Mullin Adddditional inspector Ms Jane Capron Announced 18 May 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Stubby Leas Nursing Home Address Fisherwick Road Whittington Lichfield Staffordshire WS13 8PT 01827 383496 01827 383086 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) First Care Ltd position vacant Care Home 48 PD(E) DE(E) MD(E) OP Category(ies) of 17 registration, with number 25 of places 25 23 Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 15 March 2005 Brief Description of the Service: Stubby Leas Care home that provides personal and nursing care for up to 48 service users over the age of 65 in the categories outlined below:-Dementia over 65 years of age (25), Mental Disorder, excluding learning disability or dementia - over 65 years of age (25), Old age, not falling within any other category (23), Physical disability over 65 years of age (17)The home is situated in its own grounds on the edge of Fisherwick, a rural hamlet fairly close to the city of Lichfield and Tamworth.Accommodation is provided on three levels, which are accessed, by stairs or a passenger lift. Rooms are provided on all levels of the home with a mixture of single or double rooms, some with en suite facilities.Communal areas are on the ground floor and there is a separate smoking area. The home has a purpose built activity room where service users have the opportunity to maintain their skills and hobbies or to enjoy new interests.The grounds are well maintained and very spacious. There are pleasant country views all round, with space for several cars to park. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was undertaken by two inspectors. The total time spent for the inspection, including pre and field work amounted to 16 hours. It was disappointing to note that the owner was not present at this announced inspection, particularly in light of the large amount of requirements made at the last inspection. The operational manager and proposed care manager had worked hard in preparation for this visit. Not all areas inspected were found to be satisfactory, but some positive steps had been taken to meet some of the previous requirements. A tour of the premises took place and some Health and Safety records were inspected. Care plans were examined and residents and relatives were asked to comment on the care provided within the establishment. Generally those asked were complimentary about the standards of hands on care. Several comment cards were returned to the CSCI with positive comments. Care staffing levels were deemed as too low in the afternoons and domestic input needs to be increased. Staff spoken to stated they were not receiving 3 paid days training a year, in line with national minimum requirements. The operations manager stated that they would now fund all statutory training. Training, supervision, induction and recruitment will all be reviewed thoroughly on the next inspection. The whole hot water system throughout the home needs to be serviced fully, so that residents can expect the availablitiy of hot water at all times. What the service does well:
The manager now undertakes a more comprehensive assessment of needs for each potential resident prior to admission to the Home. The care records examined indicated that health care needs are monitored and the appropriate access to medical professionals organised. The residents spoke highly of the staff team and their respect of the residents was observed. Visitors are made welcome by the staff and manager. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 6 There is a commitment to NVQ training for staff, several staff have either achieved the award or are working towards it. The ‘Getting to know you better’ plans in the main body of the care system were very comprehensive and well put together. These covered war time memories, likes, dislikes and fears. What has improved since the last inspection? What they could do better:
The Home’s Statement of Purpose and service users guide are still not a reflection of the present service delivered. These should be amended and kept under review. The care plans, although generally improved, some still require more detail to ensure that the staff have all of the information needed to meet assessed needs. Monthly reviewing must be undertaken. There is at present little evidence that all entries in to the care plans are meaningful. More effort and emphasis is required to organise suitable and varied activities and stimulation for those residents suffering with forms of dementia. Much work is required to bring the environment up to a safe and comfortable standard for its residents. A number of requirements have been made with
Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 7 regard to the environment, including Health and Safety and Fire Safety concerns. These will be revisited by the Fire officer and HSE officer. Staffing ratios for the present number of residents are not deemed sufficient. Care staff numbers must be increased by one in the afternoon shift and agency staff must be sought where permanent staff cannot do extra shifts. Domestic cover does still not provide evidence of adequate cleanliness, many areas of the home were not sufficiently clean and this needs addressing forthwith. The clinical room must be kept clean and not used for storing extraneous items. The proposed care manager has undertaken staff meetings, however staff require more structured individual supervision and induction. Duty rotas are improved but where a member of staff works a long day in two different departments, this needs to be accurately demonstrated on the duty sheet. Hot meals that are prepared for evening suppers should not be plated up before 5.30pm as the plates get too hot and the food can become dry. More Brown bread and fresh fruit and vegetables should be available. The home must provide a sanitary disposal bin for the staff. A lockable facility must also be provided for staff belongings. The dishwasher has been condemned and now needs replacing. Many of the toilet seats throughout the home are loose and needs replacing with something more robust. Toiletries must not be left in the vicinity of unlocked bathrooms. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 8 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. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 The information provided by the home did not accurately inform prospective users and others about the service provided and the contract did not clearly inform residents of the fees to be paid. Pre-admission assessments undertaken by the home enabled residents to recognise that the home could meet their needs. EVIDENCE: The Statement of Purpose and service user guide was available to residents and relatives and although recently reviewed and revised, contained a number of inaccuracies including the level of charges for items not covered by the fees. Residents were provided with a contract that outlined the services provided but one examined did not show the level of fee to be paid.
Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 11 Sampling showed that recent admissions had pre-admission assessments both by the home and by the Local authority. These covered the required areas including areas of risk. This formed the basis of the care plan. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care planning processes within the Home included aspects of health, personal and social care but need to contain meaningful statements throughout. Residents could not all expect to receive their medication in line with general practitioners prescriptions. There was a friendly, respectful ambience within the home and service users were treated as individuals, with dignity and respect. EVIDENCE: An examination was undertaken with a selection of four care plans. On one seen the basic risks assessments were in place but there was no recent bedrail assessment. There were limited comments on monthly reviews many which just stated ‘ Care plan continues’. There must be a meaningful entry when evaluating monthly care plans. There was a gap of six months between the weighing of one resident and although a loss of over 2kg was recorded, no action had been taken to address this. This particular resident could not use wheelchair foot rests and last year
Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 13 she underwent an assessment by an occupational therapist but this had not been followed up. There was no evidence of assessment for personal use of a bedroom key. The inspector engaged this residents daughter in conversation and she was very complimentary with the care and the attitude and support of the staff. The relative confirmed that she was kept informed and up to date with issues. She visits once a week and had no complaints at all. Her mother appeared well cared for, in clean clothes and had hair and nail care recently completed. This resident had been seen by an optician and a chiropodist and had a new dependency level chart in place which was reviewed monthly. A second care plan seen had a completed pre admission assessment and a care plan in place regarding communication, eating, drinking, safe environment, elimination, personal care, mobilising, activities, sleeping. Also included was a falls assessments , tissue viability profile, nutritional assessment, moving and handling assessments. Dependency level assessments were being undertaken monthly. This resident had been seen by dentist and was observed as clean and tidy and appeared well cared for. However, again there was no evidence of assessment for use of bedroom key. There was no photograph in place for this resident but this was being addressed. Two other care plans were examined and were not reviewed monthly, some entries had been made in blue ink. The ‘Getting to know you better’ plans in the main body of the care system were very comprehensive and well put together. No resident within the Home was self-medicating at the time. On inspection, there was a policy and procedure in for the receipt, storage, administration and disposal of medicines. However this had not been adhered to. Medication records were inspected thoroughly and for one resident no anomalies were found and records were correct and coincided with medication held. However for a resident who had been admitted to the some three previously and had brought three weeks of her prescribed medication with her. This had since run out but the home had only reordered her prescription last Friday. The home had been using another residents prescribed anti psychotic medication until new stocks arrived. This is a completely unsatisfactory arrangement and must cease forthwith. Residents must not be administered any medication that is not prescribed solely for their use. All medication must be administered in line with NMC requirements. Oxygen must be stored safely. This area will be checked again on the next visit. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 12,13,15 Service users had a range of religious and recreational opportunities available within the Home but this did not extend to residents suffering with dementia. Visitors were welcomed and service users were enabled and supported to fulfill their individual wishes as far as practicably possibly. The food was of a good standard, varied and nutritious but not all residents were offered choices when food was pre plated up. EVIDENCE: Activities available in the home were discussed and there was evidence of a religious service coming to the home. There is an employed activity staff member who works from Monday to Friday – 9 to 5pm, hairdressing is available in house on a Saturday. The activity staff member also undertakes escort duty, so at times can be called off her planned activity tasks. The home provide a spacious room allocated as the activity room which was currently found to be housing extraneous items including a hoist, boxes etc. These need to be removed. The activity programme provides such activities as dominoes, arts and crafts, film afternoons with popcorn, 10-12 residents go fortnightly to an over 60’s club but do have to pay for this. Apart from the over 60’s club, residents have not been out this year. It appeared during the inspection that the programme
Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 15 of activities tends to be for the same 10-12 residents and staff members confirmed that the elderly confused do not go out. The home need to ensure suitable activities are organised for those residents suffering with dementia. The was no information available to the activities available in the home and this should be clearly displayed. It was also identified that there is no budget allocated to activities and most of the outings and equipment used in the home is provided by funds raised by the staff. The home must provide a suitable budget for this, in line with their statement of purpose and service users guide. On the day of the inspection only one resident was undertaking activities as the room was found to be too cold as radiator broken. This must be repaired as soon as possible. The routines surrounding mealtimes was determined and there was a flexible breakfast time, main meal was served at lunch, where there was a choice of first course but no choice for pudding. Service users were not routinely offered an alternative such as ice cream, yoghurt, fruit. One inspector joined the residents for lunch, which was a prepared pre plated up meal including the entire contents of one of the choices of meals. Everyone was served the same, all vegetables and all had gravy. Residents should be given the choice of vegetables/gravy etc. One lady said ‘ we eat what we are given.’ There was also not much choice seen at teatime but the kitchen staff are implementing new menus with the residents input and this will be checked on the next visit. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 16,18 The arrangements for dealing with complaints were positive and constructive. Service users and their relatives/friends knew that if they wished to complain, staff would listen and make every attempt to resolve the complaint to their satisfaction if at all possible. Service users were protected from abuse by the home’s Adult Protection procedure and POVA policies. EVIDENCE: Copies of the complaints procedure were on display in the home, and included information on how to complain directly to the CSCI. One complaint had been made to the CSCI in relation to poor standards of cleanliness. This was upheld. Residents and relatives spoken to confirmed that they felt able to air their views and express their concerns to staff at any time. The home had an Adult Protection procedure that included a Whistle Blowing policy for staff. There had been no allegations or incidents of abuse at the home since the last inspection. Staff spoken to were aware of the adult protection and whistle blowing procedure and had received training in this area. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 17 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 standard(s) 19,21,25,26 There were no programmes in place to ensure upgrades and improvements in all resident areas of the home are ongoing. Major work is required to bring the Home up to an acceptable, comfortable and safe standard environmentally. EVIDENCE: A tour of the home included individual residents bedrooms and communal areas such as the lounges and the dining room. However, there was little evidence of an ongoing commitment to continue to improve all resident areas of the home. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 18 The home offered a reasonably safe environment for residents, in that the majority of radiators were covered and upstairs windows were restricted. However, there was no evidence that hot water supplies in the home were suitable for residents requirements. Seven members of staff spoken to stated that the hot water supply was very inadequate for the personal hygiene needs of the residents. In some areas water only ran cold and hot water from other areas, had to be transported around the home in bowls. One bathroom on the ground floor took up to two hours to fill. The staff stated that this bathroom would be better turned into a shower area which was a power assisted and heated water as it was drawn. A recommendation has been made to this effect. The home must keep up-to-date recording of hot water temperature tests. Adequate hand washing facilities were not available throughout the home, toilet paper and soap was required in an upstairs toilet. The clinical bin in the clinical room was in need of emptying, in line with infection control regulations. The laundry facility was fully operational. Several areas of the home, bedrooms in particular were well below acceptable levels of cleanliness and this was discussed at length. An audit on domestic duties is to be implemented. Externally, the grounds were extensive with beautiful views and accessible to all the residents. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Only limited progress has been made in addressing staffing shortages and as a result residents do not receive consistent care. EVIDENCE: Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 20 As the home has been registered under South Staffs Health Authority prior to 31st March 2002, the levels and skill mix implemented and agreed at that at that time must be maintained. On the day of the inspection the home did not have appropriate care/ancillary staff during the day shifts. The proposed care manager Mr Kevin Campbell now has some supernumerary hours to complete his management duties. There is always a qualified nurse on duty during the twenty-four hour period. To support this compliment of qualified staff there are 6 care staff on the early shift and 5 on the late shift and 2 care staff over the night shift. The home is split into two sides - The main house and the cottage. Following a discussion with the proposed care manager, administrator, 3 senior care assistants, a cook and a domestic the two inspectors were told that there are 18 service users cared for in the main house with 3 carers on in the morning and 3 on the late shift. On the cottage side it was determined that there were 29 service users with 3 care staff on in the morning and two in the afternoon. These levels are not acceptable. The staffing continues to be undertaken on an ad hoc basis and not in line with assessed needs. This is a serious situation which needs to be rectified forthwith. An assessment of the service users needs must be maintained on a monthly basis, be available for inspection and discussion when required. The provider must recruit more domestic/laundry staff to supply an adequate workforce, to meet the needs of the cleaning the home and to provide for cleaning communal toilets and busy areas in the evenings. There is an administrator employed by the home. The maintenance man works 20 hours a week for Stubby leas care home, as he is also responsible for the owners other care homes - Abidale in particular. This was seen to be the main reason why the home was in disrepair and in need of redecoration and upgrading. The registered person must recruit more staff in this field. Recruitment procedures have been firmed up and new documentation shown to the inspectors. This will be checked thoroughly on the next inspection. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The care manager has yet to be approved by CSCI but his application is being processed. Although positive results had been received from resident and relative surveys the home needs to maintain and develop its Quality Assurance processes and to act upon issues identified to ensure ongoing improvement in the service provided to the residents. Much work is required to bring the environment up to a safe and comfortable standard for its residents. EVIDENCE: From discussions with staff and the Operations Manager, it appeared that the home was being run in the best interests of residents. The home had systems for resident and relative questionnaires and these had revealed positive results. However, a number of one off audits done during
Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 22 the preceding two days, had revealed that there were a number of environmental and care issues that needed to be addressed. The home had recently started a residents meeting. The home need to develop its quality assurance systems further, maintain these systems and to act on the outcomes. Staff supervision, was ongoing but did not cover all aspects as outlined in the National minimum standards. This was discussed and the home are to develop this further. There was a flex across floor of a room and not all wardrobes were secured to the wall. The proprietor must complete all Regulation 26 visits and copies must be sent to the CSCI and filed in the home. During a tour of the home, several Health and Safety issues were noted during this inspection. An inspector from the HSE has been requested by CSCI to visit the home in the near future, to check all aspect of health and safety procedures in the home. The home had recently had a visit from the Fire Safety Officer which outlined several requirements and recommendations. The home are expected to comply with this and confirmation that all work has been completed is the sent to CSCI no later than 1st July 2005. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2
COMPLAINTS AND PROTECTION 1 x 1 x x x 2 1 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 2 2 x 3 2 x 1 Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1) 5(1) Requirement The Statement of purpose and the service user guide are required to provide accurate information of the services provided and the additional costs not covered by the fees.Previous timescale of 15/04/05 not met It is a requirement of this report that each resident must be provided with a contract which clearly identify the level of fees to be paid. Previous requirement of 15/04/05 not met.Service users must not be admitted out of category The care plans that were inspected were found to be insufficient in detail, not all current and not all reviewed regularly. You must provide a comprehensive care plan for every service user, which is current, reviewed monthly and completed in black ink previous timescale of immediate has not been met. It is a requirement of this report that al medication administered to residents in the home are prescribed soley for their use. It is a requirement of this report Timescale for action 18th June 2005 2. OP2 5(1) 18th June 2005 3. OP7 15(1) 17(1)(a) with immediate effect 4. OP9 13(2) with immediate effect with
Page 25 5. OP26 12 [1] Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 [a]16 (1)(2)(j)( k)23 (1)(a)(d)1 3 (4)(a)(b)( c) 6. OP36 18(1)(a) 7. OP27 18(1)(a) 8. OP21 23(2)(j) that all areas of the home must be maintained in a clean and hygienic condition, and that sufficient domestic staff are employed to meet this standard. Previous timescale of immediate has not been met All bathrooms and toilets must have soap, toilet paper and towels available. It is a requirement of this report that the recruitment, induction, supervision and training of staff should meet National Minimum Standards An additional member of care staff is required on each late shift.Agency staff must be used when regular staff cannot cover shifts The whole hot water system throughout the home needs to be serviced fully, so that residents can expect the availablitiy of hot water at all times immediate effect with immediate effect with immediate effect 18th June 2005 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. OP21 Refer to Standard Good Practice Recommendations The ground floor bathroom would be better turned into a shower area which is power assisted that heats water as it is drawn. Stubby Leas Nursing Home E51-E09 S22378 Stubby Leas V185815 180505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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