Care Home: Stafford Hall Care Centre

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well This home had a friendly, comfortable and welcoming atmosphere. Staff on duty were knowledgeable about service users care needs and the staff team worked together well and were enthusiastic about their work. Service users are involved, as appropriate, in the day-to-day planning of their own care and in the way the home is managed on a daily basis. Care plans are informative and help staff to understand the level of assistance service users want and need. The staff team enables service users to enjoy a good variety of leisure and social activities both in and outside of the home. Relatives and other visitors are welcome and there is a lounge where people living in the home can meet with their visitors privately. The manager wrote in the AQAA: (under what the home does well) `ensure clients are happy, comfortable, dignified. (ensure that) detailed care plans (are in place)`. `Families are an active part in the home and community and multi disciplinary teams are encouraged and invited to home`. `Staff training is provided and completed`. `Activities are provided according to the likes of the clients`. Comments made in discussions with and in surveys received from service users and relatives of service users included: `the staff are diamonds`, `I am well looked after here`, `I am very satisfied` (with the care my relative receives), `the staff are supportive and are always very patient with residents`. `they (the staff) have always been kind and caring towards my mother`. `I never dreamt my mother would settle in so well or improve so much`. `I`m amazed by the patience they (the staff) have`, I find the staff so kind and I am there often and see all the residents treated well`. What has improved since the last inspection? Care plans seen contained detailed information for staff on service users assessed daily care needs. Service users are now provided a varied daily programme of activities. Staffing deployment now ensures that service users day to day needs and expectations are met and that they are allowed/encouraged to exercise choice about how they live their lives in Stafford Hall. What the care home could do better: The flooring, skirting boards and some walls in the bathrooms are stained and damaged and need to be cleaned and/or renewed. Some walls and doorways on the first floor are chipped or damaged and need redecorating and the carpet outside room 7 is stained and so needs cleaning or replacing. CARE HOMES FOR OLDER PEOPLE Stafford Hall Care Centre 138/140 Thundersley Park Road Benfleet Essex SS7 1EN Lead Inspector A Thompson Unannounced Inspection 15th & 22nd July 2008 09:45 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 Stafford Hall Care Centre DS0000067736.V368418.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. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stafford Hall Care Centre Address 138/140 Thundersley Park Road Benfleet Essex SS7 1EN 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) 01268 792727 01268 795932 stafford.hall@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc Joanne Cauchi Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th July 2007 Brief Description of the Service: Stafford Hall is a two storey building situated in South Benfleet, which is registered to provide care and accommodation for up to forty people. The original property has been considerably extended over the years to provide the current level of facilities and accommodation. There are single and double bedrooms on the ground and first floors. There are two main communal areas, one is used as a lounge and the other as a dining room. In addition there is a small quiet lounge area that doubles as a visitors room. The first floor is accessed via a passenger lift. The home has a good sized rear garden with decking and seating. This is accessed from the first floor level. There is space for visitor parking at the front of the property, and local bus services run along Benfleet High Road which is a short walk away. Fees at Stafford Hall range from £367.15 per week for a local authority room, £502.00 for a private single room and £650.50 for a premier room. CSCI inspection reports can be obtained from the home, or via the CSCI internet website: www.csci.org.uk. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection commenced on Tuesday 15th July 2008, with a second announced visit taking place on Tuesday 22nd July to complete the process. The content of this report reflects the inspector’s findings on the day/s of the inspection along with information provided by the service and feedback by service users, staff and other parties. The new registered manager (in post since the last key inspection) was at the home on both days of the inspection, as was Runwood Homes Operations Manager. Both assisted the inspection process. The manager had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to the inspection. This document gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as their future plans for improving the service. Some of the information and detail provided within the AQAA has been included in this report. Discussions were entered into with the manager, service users, the operations manager, visitors and staff on duty. CSCI survey questionnaires were also provided to service users, staff and stakeholders. We received fifteen completed surveys and reference to feedback from these has been made within this report. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All matters relating to the outcome of the inspection were discussed with the manager of the home, with full opportunity for discussion given and/or clarification where necessary. What the service does well: This home had a friendly, comfortable and welcoming atmosphere. Staff on duty were knowledgeable about service users care needs and the staff team worked together well and were enthusiastic about their work. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 6 Service users are involved, as appropriate, in the day-to-day planning of their own care and in the way the home is managed on a daily basis. Care plans are informative and help staff to understand the level of assistance service users want and need. The staff team enables service users to enjoy a good variety of leisure and social activities both in and outside of the home. Relatives and other visitors are welcome and there is a lounge where people living in the home can meet with their visitors privately. The manager wrote in the AQAA: (under what the home does well) ‘ensure clients are happy, comfortable, dignified. (ensure that) detailed care plans (are in place)’. ‘Families are an active part in the home and community and multi disciplinary teams are encouraged and invited to home’. ‘Staff training is provided and completed’. ‘Activities are provided according to the likes of the clients’. Comments made in discussions with and in surveys received from service users and relatives of service users included: ‘the staff are diamonds’, ‘I am well looked after here’, ‘I am very satisfied’ (with the care my relative receives), ‘the staff are supportive and are always very patient with residents’. ‘they (the staff) have always been kind and caring towards my mother’. ‘I never dreamt my mother would settle in so well or improve so much’. ‘I’m amazed by the patience they (the staff) have’, I find the staff so kind and I am there often and see all the residents treated well’. What has improved since the last inspection? What they could do better: The flooring, skirting boards and some walls in the bathrooms are stained and damaged and need to be cleaned and/or renewed. Some walls and doorways on the first floor are chipped or damaged and need redecorating and the carpet outside room 7 is stained and so needs cleaning or replacing. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Stafford Hall Care Centre DS0000067736.V368418.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 Stafford Hall Care Centre DS0000067736.V368418.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that information provided by the home enables them to make an informed choice and that assessments provide sufficient details on their personal and healthcare needs. EVIDENCE: The manager or a care team manager (CTM) visits prospective new service users to undertake an assessment of need. Evidence of this process was seen in files for people admitted since the last inspection. Assessment headings covered included: background information, personal care, communication, behaviours, pressure care, safety, religious, family contact, mobility, personal hygiene, diet, vision, hearing, continence, manual handling, sleep, medication, oral care, falls, social needs and a dementia assessment. Copies of assessments carried by the placing authority were also seen. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 10 The manager confirmed that trial visits are available for prospective new service users and discussions with relatives and service users confirmed this. One said ‘we could look at the home as often as we liked before deciding if it was what we wanted’. A care plan is compiled after admission, as seen on individual files. Information provided by the manager in the AQAA relating to admission states: (we) ‘invite people in to look at all areas of home. (we) Provide literature to take away (statement of purpose). Encourage them to visit other homes in area to be able to make an informed choice. Provide them with the CSCI website so they can read all reports. All clients are assessed before moving into the home and when medically fit for discharge from hospital, to ensure that we are able to meet the needs of the individual. Although the home does not provide intermediate care, new service users either private or socially funded are reviewed after 6 weeks in which all aspects of their care and wellbeing are discussed with themselves and family’. Stafford Hall Care Centre DS0000067736.V368418.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are successful in delivering appropriate care and treating service users with respect when providing for their care needs. Care needs are documented and recorded appropriately which means that service users can be assured that their needs will be met. EVIDENCE: Four care plans were inspected. Included was background information, personal details, and next of kin contacts. Assessments of identified needs were recorded with instructions of the care required to meet these needs. Areas of assessment were based on those identified upon admission and added to afterwards. Care plans seen included a dependency assessment and risk assessments on pressure care, nutrition, manual handling, falls, mental health and general risks. There were records of reviews and of daily staff observations, weight had been recorded and records had been kept of GPs visits and treatment and on any other medical consultations. There was a separate care plan for night time needs. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 12 Care plans are reviewed regularly by the Care Team Manager with key workers involved in ensuring that daily notes record any changing needs. All care plans seen had been signed as agreed by the service user and appropriate relative, and the manager. The manager said that Stafford Hall gets good support from District Nursing services on pressure care assessment and with the supply of appropriate aids and treatment. Continence issues are supported by the community continence nurse with the home’s CTM ensuring regular communication and updates on changing service users continence needs. Hearing needs are provided for by GP referral to a local hospital. Dental check ups and treatment is provided to service users by visiting a community based dentist. Care of dentures is provided by a practitioner who visits the home, as does a chiropodist and an optician. Records of visits with written outcome notes were seen. The homes medication policies and procedures were seen and included instructions on ordering, receipt, storage, administration, self medicating and returns of unused stocks. Staff had been trained on medication issues, certificates of attendance were seen. Only CTMs or the manager deal with medication and competency assessments are carried out before staff take on this role. Evidence of these was seen. Medication administration records were inspected no shortfalls were noted. Discussions with individual service users and comments made in surveys returned confirmed that they thought they were treated with respect by staff, and staff on duty were seen to be patient and helpful in their dealings with service users. Comments made included ‘the staff here are very good’ , ‘the staff are helpful’, I’m happy here’. Information provided by the manager in the AQAA relating to these standards states: ‘Care plans are based on individuals not the needs of the home. care plans are person centred and focus on the needs of the individual on all activities of daily living. Families are encouraged to continue to be an important part of the clients life and views and opinions are respected Risk assessments are appropriate and updated regularly. Changing needs such as continence and nutrition are closely monitored. Outside agencies such as GP district nurses. Nurse practitioner and chiropodist are an important part of the home to ensure a complete service to the clients. Close links with pharmacist and GP’s ensure that medication is appropriate and well managed. Privacy and dignity are paramount and care plans are person centred to reflect this’. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. People living in Stafford Hall can expect to have a lifestyle that matches their expectations through opportunities for activity, and enjoyable food. EVIDENCE: Service users meetings had taken place and minutes of issues discussed had included food, activities, the garden, rooms and staff. The manager said that these meetings take place once a month. The home has two activities coordinators, both had been trained in ‘activities based care’. There was a programme of planned activities displayed in the hallway and individual records had been kept of activities offered daily to each service user. These included games, cards, discussions, walks and shopping trips, massage, indoor games, bingo, quizzes, reminiscence, indoor exercise, arts & crafts and visiting entertainers. Outings had begun, Dial a Ride transport is used for this. Places visited so far included local country parks. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 14 The activities co-ordinator said that a local church group visit weekly to meet with service users and every Sunday local clergy visit to hold a service in the home. A hairdresser visits weekly. Activities were seen happening on both days of the inspection and visitors spoken with confirmed that this was normal for the home. Two Service users spoken with said they took part in activities on most days and that they were usually enjoyable, although some spoken with were not interested in taking part at all. When asked, service users told the inspector that their family and friends could visit at anytime and that staff always made them welcome. Four relatives spoken with confirmed that they visit regularly and that they are always made welcome by staff. Inspection of private rooms evidenced that service users had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from service users, who, when asked, told the inspector of the furniture and personal items they had brought in with them. Information on independent advocacy support was displayed in the home with advice leaflets from an organisation called ‘Care Aware’ available for reference by service users and relatives. The manager had also compiled a folder with information how to contact advisory organisations regarding choosing a care home and related financial issues. Nutrition records evidenced choice and variety. Portion sizes eaten had been recorded so that staff can see quickly if a service user looses their appetite. The cook confirmed that the main daily meal is lunch with at least two choices and that there is also a choice at tea. Cooked breakfasts are taken by some service users and suppers are available to those who feel hungry at night. Food stocks were good and service users spoken with were satisfied with the food and confirmed that there was always a choice. One service user said ‘the food is good and it satisfies me’. Relatives spoken with said the food ‘looked good’ and ‘was good’. Information provided by the manager in the AQAA relating to these standards states: ‘Clients are offered choices on all aspects of their daily life including choice of clothes, the way in which they require to be assisted with personal hygiene, food choices. Religious beliefs are respected and receive regular appropriate services’. ‘Activities have vastly improved, outings now take place regularly’. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 15 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. People are able to raise concerns about the service and the staff’s training provision and managements’ response to complaints and safeguarding concerns has promoted peoples’ safety and well being. EVIDENCE: The complaints procedure was seen and contained guidance on how to make a complaint and who to complain to. Also included were timescales for responses from staff. There was a standard template for staff to record any concerns and evidence was seen to confirm that records are maintained in the home of complaints received and of any investigation and resulting outcomes. Information in the AQAA states that three complaints had been received since the last key inspection, records inspected evidenced that these had been dealt with appropriately. Service users spoken with said they knew who to speak to if they had any concerns, and they seemed confident that any concerns would be investigated properly. Relatives spoken with were also confident that complaints or concerns would be dealt with appropriately. The homes policy on adult protection was inspected. There was written guidance for staff on recognising and reporting abuse, and action to be taken Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 16 by staff if abuse is suspected, including a procedure flowchart and a recording information. Staff spoken with displayed awareness of this subject and procedure and had received training on adult protection procedures, certificates were seen to evidence this. There was also had a written ‘whistleblowing’ policy which provided guidance to staff on their responsibilities to report any concerns to the manager. Information provided by the manager in the AQAA relating to these standards states: ‘The complaints procedure is clearly visible to clients, relatives and staff. Complaints/concerns are investigated within 48 hours and where possible actions taken and persons involved are notified accordingly. Advocacy services are easily accessible. Staff are recruited under strict scrutiny of police checks and references. Staff training regarding safe guarding adults is carried out yearly. Whistle blowing is explained at interview, induction and process documented in staff room, all money within the home is safeguarded and precise documentation is in order’. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a mostly well maintained environment however some bathrooms need attention to ensure that service users have access to good facilities throughout the home. EVIDENCE: Stafford Hall provides a comfortable and mostly well maintained environment. The site visit included a tour of the premises when it was noted that the home was clean and tidy, and there was no evidence of any unpleasant odours. The bedrooms, lounges and dining room were well decorated but some corridor areas would benefit from redecoration, and some bathrooms had stained flooring and damaged/chipped skirting boards and walls that require attention. Carpets and furnishings were of a good quality, however the carpet outside rooms 7 & 8 on the ground floor was dirty/stained. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 18 The bathrooms did have aids and adaptations to meet the needs of the people using the service, and there were sufficient toilets sited close to communal rooms. All four bathrooms had wcs and there were six separate communal wcs, with two private bedrooms having their own en-suite wc. Bedrooms seen were acceptably decorated, clean, comfortable and made homely with people’s personal possessions. During discussion with service users all who expressed a view confirmed that their rooms were comfortable and kept clean. Comments made included, ‘my room is cleaned every morning, ‘this place is like a palace compared to others I’ve seen’ and ‘my room is kept clean for me’. Some rooms also had private balconies at the front of the home. A large communal lounge and separate dining room were provided on the ground floor and these were generally bright and spacious. The rear garden areas were accessed by a walkway from the first floor. This led to a pleasant area of wooden decking with seating. The manager said plans were in hand to further improve level pathway access to other areas of the garden. The laundry was at the rear of the home on the ground floor. The equipment in place was suitable for the size of the home but the space available for staff to work in was very limited considering the numbers of people who live in Stafford Hall. Information provided by the manager in the AQAA relating to these standards states: ‘Maintenance schedules reflect need of home whilst maintaining a homely feel. Water temperatures checked and documented monthly. communal areas are free from obstruction and privacy adhered to at all times. The garden is now used by clients’ Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 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 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. People living at Stafford Hall are supported by staff who have training to ensure they have the skills for their roles. The recruitment practices used have promoted and protected service users welfare and safety. EVIDENCE: The home’s staffing rota was inspected and showed daytime staffing levels as four carers on duty plus a care team manager (CTM). The managers hours are supernumery. Night staffing is two waking carers and one CTM. In addition to the care staff there are two cooks employed who between then work every day and three part kitchen assistants, one of these covers breakfast. The home also has an administrator, one housekeeper, a laundry person seven days a week, two domestic staff, two activities coordinators and a maintenance person. Discussion with staff and records confirmed that regular staff meetings are held, minutes of meetings held were seen. Four files were inspected for staff employed since the last inspection. Evidence was seen to confirm that application forms had been completed, interviews held with notes and an interview assessment completed, written references Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 20 obtained, written terms & conditions issued, and criminal records checks undertaken. Copies of proof of ID, photographs and job descriptions were also on files. Staff are encouraged to undertake NVQ training and evidence was seen to confirm 80 of carers either have or where training for their NVQ level 2 or 3 awards. NVQ training has also been provided to catering and administrative staff. Evidence was seen to confirm that new staff undergo initial 4 week induction training. This includes issue of a welcome pack devised by the manager to clarify the expectations of workers roles. Soon after the four week basic induction is completed new staff then have 3 months to complete the full Skills for Care Common Induction Standards format. Staff spoken with confirmed they received induction training, they also confirmed that the manager is supportive and will respond quickly to any queries or concerns they may have regarding service users well being. All staff have an individual training record and there is a training matrix which identifies training undertaken for the whole team, as well as when updates are due. Training records seen and discussion with staff confirmed that staff had been provided training on: induction, dementia, safeguarding (adult protection), medication, first aid, health & safety, fire safety, manual handling, food hygiene, effective communication, COSHH (hazardous substances control), challenging behaviour, parkinsons awareness, activities for people who have dementia and NVQ. The manager advised that she will soon be providing in-house training on epilepsy and diabetes awareness. Information provided by the manager in the AQAA relating to these standards states: ‘Concise rota’s to show who on shift at any given time. Staff all undertaking or about to commence NVQ 2 as agreed at interview. Core training is of high importance and all staff receive them yearly and as soon as possible when they start at the home. Stringent recruitment policy. Detailed induction completed’. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 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 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, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users and their health, safety and welfare are promoted and protected. EVIDENCE: Since the last inspection of Stafford Hall in 2007 there has been a change in manager. The new manager is a registered nurse and said she had fifteen years experience in the care/nursing sector, including four years in working on an elderly actute nursing ward in a general hospital. The manager has undertaken training to update her knowledge and skills and has enrolled on the management modules for the registered managers award (NVQ level 4). The quality assurance (QA) process at Stafford Hall involves an annual audit of the service by the registered provider. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 22 A copy of this comprehensive assessment has been provided to us. This exercise includes writing to service users, relatives and health and social care professionals involved in the home to ask their views on the service provided. Responses in surveys were seen included in the report. The most recent audit report was completed in April 2008 and from this an annual development plan is compiled and the manager produces an action plan to deal with any issues raised. This was seen at the inspection. Other quality monitoring processes evidenced as used to gather views/opinions included staff surveys, catering surveys, a comments & suggestions box in the home, service user meetings and relatives meetings. The administrator advised that personal allowance monies are held for safe keeping for all service users. Records had been kept of the balances held and of receipts for expenditure. A random sample of these were checked and found to be in order. Staff had received regular recorded 1-1 supervision from the management team. Records of this process were seen and included discussion on service users, training, personal development and actions to be taken. Staff spoken with said they received 1-1 supervision and support and that regular staff meetings took place. Random samples of records required to be kept were inspected. These included: accidents, complaints, assessments, care plans, staff rotas, staff recruitment, visitors book, fire drills, nutrition, medication, background info’ and next of kin details, regulation 26 reports (registered provider reports) and fire procedures. All seen were satisfactory. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling, fire safety, food hygiene, first aid and infection control. Certificates and service records were seen to confirm that the home’s hoists, fire equipment & alarms, passenger lifts, gas boilers, portable electrical appliances and electrical installation supply had all been tested/serviced. Hot water temperature is regulated and manual checks are also carried out regularly, these were seen. Information provided by the manager in the AQAA relating to these standards states: ‘ The manager is registered nurse and has previous experience on an acute medical ward for the elderly. Manager gives clear guidelines of standards expected and is frequently on the rota to ensure high quality care is monitored. Staff able to raise issues and concerns at all times. Quality assurance is ongoing with audits yearly. Reports are actioned and staff able to view these and encouraged to be active within this’. Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 23 Requirement Stained floor coverings and chipped /damaged skirting boards and walls in the home’s bathrooms, and in some corridor areas need to be cleaned/repaired/replaced as necessary to ensure that service users live in a clean, well maintained environment. Timescale for action 30/11/08 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 OP19 Good Practice Recommendations The corridor walls outside bedrooms 7 & 8 on the ground floor and to some corridor areas on the first floor should be redecorated to provide a clean and well maintained environment for service users to live in. Consideration should be given to increasing the size of the laundry so that staff have sufficient space to work in. 2 OP26 Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Stafford Hall Care Centre DS0000067736.V368418.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!