Care Home: Stanborough Lodge

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What the care home does well Information about the home including the ‘Statement of Purpose’, ‘Service User’s Guide’ and a complaints procedure was available to prospective and current residents. This ensures people have appropriate information about the service. An assessment of needs for each individual was carried out prior to admission and residents spoken to said that they were able to visit and view Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 the home before making a decision whether to move in or not. This ensures for both parties that Stanborough Lodge can meet the person’s needs and is the right home for them. We looked at three care plans and found them to contain very good information on the residents. Where needs were recognised there were good directions to staff on how to meet that need. People who required nursing care had regular input from the District Nurses. All residents are registered with a GP and a log of visits from them, District Nurses and all other health care professionals are kept. Residents also have access to visiting Chiropodists, Dentists and Opticians. All our observations and speaking to residents assured us that all residents were treated with respect and dignity and their rights to privacy was respected. There was a relaxed atmosphere and good interaction between staff and people living in the care home. There was a weekly programme of activities posted on the notice board .Some residents were listening to music, reading newspapers; chatting to each other and watching T.V. Other activities including the booking of entertainers, trips to places of interests and access to local community facilities are also planned. Residents spoken to confirmed that they enjoyed going to parks, shopping and visit to the local garden centres. Representatives from the local church and pupils from schools also visit the home. On the day of the inspection the home where residents have access to was kept clean, fresh and well maintained. People’s rooms were personalised and reflected their individuality. People using the service and their relatives said that there is a good team of staff who are caring and helpful. There was adequate number of staff rostered on duty per shift during the day and night so that they are able to meet the needs of people using the service. There were also adequate number of domestic and catering staff allocated per day and the home has the services of a fulltime maintenance person. Feedback received from people living in the home, their relatives and staff was positive. Staff spoken to said that there is an open management culture and good teamwork, which promotes the interests and well-being of residents. There is a quality assurance system in place covering all aspects of the service provided including resident’s rights and quality of life. The auditing systems provide evidence that action is taken to address any shortfalls identified. This ensures peoples opinion are sought and the service is delivered safely. In relation to Equality and Diversity, the home treats each resident as an individual, taking into account their physical needs, cultural and religious beliefs and personal tastes. They also employ staff from various ethnic backgrounds and cultures. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? All the requirements made in the last inspection report were met. As stated in the AQAA, the registered manager has put together a new information pack to give to prospective clients, when they come to look around the home. To help maintain people’s independence a new electrically operated bath and hoist with shower attachment has been purchased. New chairs have been bought for the main lounge and new carpets fitted to stairs landing, hallways and one of the bedrooms. What the care home could do better: So that people have the most relevant information the ‘Statement of Purpose’ and the ‘Service User’s Guide should be updated to provide the correct details of the Commission. Care plans should be signed by the residents or their relatives/representatives to indicate that the plans were drawn up with their involvement and agreed by them. The current system for returning of medicines to pharmacy for disposal should be explored further as the driver signs for the medicines taken and not the pharmacist for medicines received. There are certain risks when taking anticoagulant medication and therefore a risk assessment must be carried out for those residents who are taking Warfarin so that staff are aware of the possible risks and the necessary action to take to manage these risks. The floorings throughout the kitchen were very badly stained and are in need of replacement. The sinks in the main kitchen and the shelves in the store room were also very badly stained and in need of cleaning or replacement. OneStanborough LodgeDS0000019585.V377513.R01.S.doc Version 5.2 of the fluorescent lights in the main kitchen did not have a cover as required by the Health and Safety regulations. The other two that did have covers, we saw that these contained dead flies and insects (the handyperson cleaned these covers when we brought this to his attention). Food cooked previously and stored in the fridge must be labelled and dated to avoid food poisoning. Staff preparing food should be provided with food hygiene training and this training should be repeated every three years as stated on the certificates. These must be carried be out so that food is stored and prepared in a clean environment. Where an error has been made by staff when recording in residents’ care plans, sticky labels must not be used to cover the errors. The error should be crossed through and initialled. Doors must only be held opened by means approved by the Fire Safety Officer and not wedged open so that residents are not put at risk. Old and broken furniture, bath tub and other building materials that are left in the front garden should be removed and disposed of so as to compliment the well maintained grounds of the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Stanborough Lodge Great North Road Welwyn Garden City Hertfordshire AL8 7TD Lead Inspector Bijayraj Ramkhelawon Key Unannounced Inspection 4th September 2009 09:45 DS0000019585.V377513.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanborough Lodge Address Great North Road Welwyn Garden City Hertfordshire AL8 7TD 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) 01707 275917 01707 258405 rmd12@btconnect.com RMD Enterprises Limited Ms Sheila Pearce Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2008 Brief Description of the Service: Stanborough Lodge is a detached two storey Georgian-style property that has been converted to its present use. The building comprises of twenty-three bedrooms, each with an en-suite facility. The bedrooms are located on both floors. There are two main lounges one of which is delegated as the smoking lounge, a conservatory and dinning room. There are separate bathrooms and toilets available on each floor. All parts of the building are accessible to persons with restricted mobility. Aids and adaptations include a passenger lift; grab rails and a ramp leading from one door to aid those with restricted mobility access the garden and patio areas. There is a large, well-maintained garden with level pathways. The home is located in a quite cul-de-sac close to the A1M motorway. It is located within short distance from parkland, a local public house, local shops and amenities. Information regarding the service is available in the Statement of Purpose and Service User Guides. These documents and a copy of the most recent inspection report should be available on request from the manager. The fees range from £437.78 - £525 per week. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection was carried out on the 21st July 2008. The overall quality rating for this service has been judged to be 2*, GOOD. This means that people who use the service experience good quality outcomes. This unannounced key inspection was carried out on the 4th September 2009 and took one day. Although the inspection was conducted by just one inspector representing the Commission, for the purposes of this report this will be stated as ‘we’. It included talking to people using the service, their relatives and visitors, staff, examining care plans, medicine records, staff files, staff training records, fire safety procedures, maintenance records, all other records and documents and a tour of the premises. Information received by the Commission since the last inspection has also been reviewed. We looked at all the information we have asked for or received about the home, since the last inspection. This information included the Annual Quality Assurance Assessment (AQAA), sent by and returned to the Commission from the provider. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. The document returned to us was satisfactory, although there were areas where more supporting evidence would have been useful to illustrate what the home is planning to do so as to improve the quality of service provision. The information provided in the AQAA was also checked against the findings as set out in the past inspection report. On the day of the inspection there were 21 residents in the care home and the majority of them were spoken to. Feedback received from them and visitors was positive. They were complimentary of staff, food and the services they received. What the service does well: Information about the home including the ‘Statement of Purpose’, ‘Service User’s Guide’ and a complaints procedure was available to prospective and current residents. This ensures people have appropriate information about the service. An assessment of needs for each individual was carried out prior to admission and residents spoken to said that they were able to visit and view Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 6 the home before making a decision whether to move in or not. This ensures for both parties that Stanborough Lodge can meet the person’s needs and is the right home for them. We looked at three care plans and found them to contain very good information on the residents. Where needs were recognised there were good directions to staff on how to meet that need. People who required nursing care had regular input from the District Nurses. All residents are registered with a GP and a log of visits from them, District Nurses and all other health care professionals are kept. Residents also have access to visiting Chiropodists, Dentists and Opticians. All our observations and speaking to residents assured us that all residents were treated with respect and dignity and their rights to privacy was respected. There was a relaxed atmosphere and good interaction between staff and people living in the care home. There was a weekly programme of activities posted on the notice board .Some residents were listening to music, reading newspapers; chatting to each other and watching T.V. Other activities including the booking of entertainers, trips to places of interests and access to local community facilities are also planned. Residents spoken to confirmed that they enjoyed going to parks, shopping and visit to the local garden centres. Representatives from the local church and pupils from schools also visit the home. On the day of the inspection the home where residents have access to was kept clean, fresh and well maintained. People’s rooms were personalised and reflected their individuality. People using the service and their relatives said that there is a good team of staff who are caring and helpful. There was adequate number of staff rostered on duty per shift during the day and night so that they are able to meet the needs of people using the service. There were also adequate number of domestic and catering staff allocated per day and the home has the services of a fulltime maintenance person. Feedback received from people living in the home, their relatives and staff was positive. Staff spoken to said that there is an open management culture and good teamwork, which promotes the interests and well-being of residents. There is a quality assurance system in place covering all aspects of the service provided including resident’s rights and quality of life. The auditing systems provide evidence that action is taken to address any shortfalls identified. This ensures peoples opinion are sought and the service is delivered safely. In relation to Equality and Diversity, the home treats each resident as an individual, taking into account their physical needs, cultural and religious beliefs and personal tastes. They also employ staff from various ethnic backgrounds and cultures. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: So that people have the most relevant information the ‘Statement of Purpose’ and the ‘Service User’s Guide should be updated to provide the correct details of the Commission. Care plans should be signed by the residents or their relatives/representatives to indicate that the plans were drawn up with their involvement and agreed by them. The current system for returning of medicines to pharmacy for disposal should be explored further as the driver signs for the medicines taken and not the pharmacist for medicines received. There are certain risks when taking anticoagulant medication and therefore a risk assessment must be carried out for those residents who are taking Warfarin so that staff are aware of the possible risks and the necessary action to take to manage these risks. The floorings throughout the kitchen were very badly stained and are in need of replacement. The sinks in the main kitchen and the shelves in the store room were also very badly stained and in need of cleaning or replacement. One Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 8 of the fluorescent lights in the main kitchen did not have a cover as required by the Health and Safety regulations. The other two that did have covers, we saw that these contained dead flies and insects (the handyperson cleaned these covers when we brought this to his attention). Food cooked previously and stored in the fridge must be labelled and dated to avoid food poisoning. Staff preparing food should be provided with food hygiene training and this training should be repeated every three years as stated on the certificates. These must be carried be out so that food is stored and prepared in a clean environment. Where an error has been made by staff when recording in residents’ care plans, sticky labels must not be used to cover the errors. The error should be crossed through and initialled. Doors must only be held opened by means approved by the Fire Safety Officer and not wedged open so that residents are not put at risk. Old and broken furniture, bath tub and other building materials that are left in the front garden should be removed and disposed of so as to compliment the well maintained grounds of the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with information about the home to assist them in making a decision whether to use the care home or not. They can be sure that their needs would be assessed before moving into the home EVIDENCE: Information about the home including the ‘Statement of Purpose’ and ‘Service User’s Guide’ was available to prospective and current residents. However, both these documents we saw need to be updated to provide the correct Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 11 details of the Commission. A copy of each document is available at the front entrance of the care home. An assessment of needs for each individual was carried out prior to admission and residents spoken to said that they were able to visit and view the home before making a decision whether to move in or not. This ensures for both parties that Stanborough Lodge can meet the person’s needs and is the right home for them. As stated in the AQAA, the registered manager will within the next twelve months devise and implement a body chart for new residents so that any bruises, pressure ulcers or broken skin can be recorded on admission. Residents will be asked to complete a list for their valuables and will be given the opportunity to decide whether they would be happy to handover their valuables for safekeeping in the safe. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive assistance with their personal and health care in a manner they prefer that ensures their identified needs are being met in a dignified and respectful manner. EVIDENCE: We looked at three care plans and found them to contain very good information on the residents’ needs. Where needs were recognised there were good directions to staff on how to meet that need. People who required nursing care had regular input from the District Nurses. All residents are registered with a GP and a log of visits from them, District Nurses and all other health care professionals are kept. District nurses attend to nursing care that a resident may require and residents also have access to visiting Chiropodists, Dentists and Opticians. However, two of these care plans were not signed by Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 13 the residents or their relatives/representatives to indicate that the plans were drawn up with their involvement and agreed by them. All our observations and speaking to residents assured us that all residents were treated with respect and dignity and their rights to privacy was respected. There was a relaxed atmosphere and we saw good interaction between staff and people living in the care home. The records for the administration and management of medicines were kept in good order thus ensuring that safe practices were being maintained. The medicine record charts showed that medicines were given as prescribed and unused medication was returned to the supplying pharmacy. A monthly audit of the system including the ordering, storage, administration and disposal of medicines was carried out to ensure that residents received their medicines as prescribed. The current system for returning of medicines to the pharmacy for disposal should be explored further as the driver signs for the medicines taken and not the pharmacist for medicines received. One of the residents is on Warfarin (anticoagulant) medication and did not have a risk assessment to say that there are certain risks when taking this medication so that staff are aware of these possible risks and the necessary action to take to manage these risks. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can be sure that visitors are welcomed at all reasonable times. A variety of activities are available giving people an opportunity to pursue their leisure, social, recreational and cultural interests. The food is served in a pleasing manner, which meets people’s needs and expectations. EVIDENCE: There was a weekly programme of activities posted on the notice board. Each resident has an activity profile that includes each person’s hobbies, interests and leisure activities. On the day of the inspection, it was one of the residents’ birthday and staff were getting the other residents ready for the celebration. Some residents were listening to music, reading newspapers; chatting to each other and watching T.V. The home provides a variety of games, jigsaws, painting and books supplied by the mobile library. Other activities including the Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 15 booking of entertainers, trips to places of interests and access to local community facilities are also planned. Residents spoken to confirmed that they enjoyed going to parks, shopping and visit to the local garden centres. Representatives from the local church and pupils from schools also visit the home. Some people manage their own financial affairs with the help of their relatives and a representative from Age Concern visits the home on a regular basis to offer advice and help to residents if needed. Personal belongings were evident in individual bedrooms. We saw that the mealtime was conducted at a leisurely pace in the dining room. We saw that the tables were set very nicely and the food was served in an orderly manner and the residents did not have to wait too long to be served. The food was of good appearance. The residents appeared to enjoy it. Residents spoken were complimentary of the staff, food and the support they received. One resident said ‘staff are very polite and caring. A lady comes to do quiz, reminiscing sessions and manicures’. Another said ‘I go out during the day. Sometimes to the lakes and fields and sometimes stay in and participate in quiz and play games’. As stated in the AQAA, the registered manager will within the next twelve months plan regular residents meetings and improve the current activity programme. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that their concerns and complaints would be listened to and acted upon and that they would be safeguarded from abuse, neglect and harm. EVIDENCE: A copy of the complaints procedure was available to people living in the care home. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. Staff files examined and staff spoken to confirmed that they have received training on Safeguarding Adults. One complaint was received since the last inspection and records showed that this dealt with in accordance with the home’s complaints procedure. There have been 6 compliments received during the same period. Currently, one safeguarding incident is being investigated by the Adult Care Services Safeguarding Team that is nearing conclusion. This was referred by the QE Hospital when a resident attended the hospital. The registered manager said that the Safeguarding Team found that the home did everything right to support the resident as they did. We are awaiting for a copy of the strategy meeting. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 17 Stanborough Lodge DS0000019585.V377513.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can be sure that they will live in a clean, fresh and comfortable environment that is safe, well maintained and meets their needs. EVIDENCE: On the day of the inspection the home was clean and fresh and well maintained. People’s rooms were personalised and reflected their individuality. As identified in the last inspection that there is nothing in place to stop vulnerable people leaving the grounds of the home and wandering into the road when in the garden. The Registered Manager said that a fence with a gate will be fitted by the side of the building and at present yellow stripped tapes Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 19 have been placed across to stop any resident walking out. We saw that Old and broken furniture, bath tub and other debris were left in the front garden that should be removed and disposed of so as to compliment the well maintained grounds of the home. We saw that the general décor of the kitchen needed to be attended to. The floorings in the main kitchen and the food store room, the sinks and the shelves in the stored room were showing signed of wear and were very badly stained. One of the fluorescent lights in the kitchen did not have a cover while the other two that had been provided with covers were noted to be full of dead flies and insects (both covers were cleaned on the day of the inspection when the inspector pointed these out to the handyperson). According to the chef on duty, there has not been a deep clean of the kitchen for over 4 years and this should be done on a regular basis so that food is prepared in a clean environment. We noted that two of the residents’ bedroom doors were wedged open. One resident said they preferred the door to be left ajar. Doors must only be held opened by means approved by the Firs Safety Officer and not wedged open so that residents are not put at risk. As stated in the AQAA, the registered manager will within the next twelve months carry out a feasibility study to convert the upstairs bathroom into a shower room and will re-carpet bedrooms 14 and 15. Stanborough Lodge DS0000019585.V377513.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service do benefit from the care and support they receive from a competent and trained staff team and that they feel protected by the home’s recruitment policy and practices. EVIDENCE: People using the service and their relatives said that there is a good team of staff who are caring and helpful. There was adequate number of staff rostered on duty per shift during the day and night so that they are able to meet the needs of people using the service There were also adequate number of domestic and catering staff allocated per day and the home has the services of a fulltime maintenance person so as to ensure that the environment is well maintained and residents receive freshly prepared meals. We looked at five staff files. These confirmed that there are now robust processes in place to ensure suitable people are employed and the required checks, including two written references are received and Criminal Records Bureau checks are carried out prior to staff being employed. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 21 There is a staff training and development programme in place for all staff, which ensures they are up to date and feel confident in their roles. Currently, there are 13 care staff employed at the care home. 4 of whom have completed the NVQ Level 2, one at Level 3 and another at Level 4. Staff spoken to confirmed that they received regular formal supervision and felt that the overall support provided was good. Stanborough Lodge DS0000019585.V377513.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured with some exceptions that the home makes every effort to ensure that the home is well run in the best interests of the people who live there and that their health and welfare is promoted. EVIDENCE: Feedback received from people living in the home, their relatives and staff was positive. Staff spoken to said that there is an open management culture and good teamwork, which promotes the interests and well-being of residents. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 23 There is a quality assurance system in place covering all aspects of the service provided including resident’s rights and quality of life. The auditing systems provide evidence that action is taken to address any shortfalls identified including the shorfalls in food hygiene found, the wedged doors and the records with a sticky label. All the above are being addressed by the registered manager and the responsible individual. Staff receive the required statutory health and safety training to carry out their jobs and protect residents. However, as reported in the environment section, we noted that two of the residents’ bedroom doors were wedged open. One resident said that they preferred the door to be left ajar. Doors must only be held opened by means approved by the Fire Safety Officer and not wedged so that residents are not put at risk. Records of accidents, incidents and checks on health & safety and fire equipment are recorded and regularly reviewed. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Staff spoken to were aware that people using the service can access their records and information held about them in accordance with the Data Protection Act 1998. A safeguarding incident is being investigated and the recording in this care plan where an entry was made by mistake, this was covered with a sticky label and written over. Staff spoken to said that this practice is no longer used and that they are aware of what to do should they make an error in recording in residents’ documents. The overall policy of the home is that they do not manage any of the residents’ money. However, as stated in the AQAA, there is a safe in the office, where residents can deposit their personal allowances or valuables for safe keeping. There were policies and procedures in place to ensure that the health, safety and welfare of people using the service and staff are promoted and protected. These records were accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The Commission has been kept informed of all accidents and admissions to hospital. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million and expires on the 28th June 2010. Equality and diversity issues are understood by the staff team and addressed for individuals through their care plans, which describe how individual needs, and preferences are to be met. Policies and procedures are adjusted in response to changing legislation and guidance. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 24 We saw food that was cooked previously and stored in the fridge (roast chicken and sliced ham) were not labelled and dated. This must be done so as to avoid food poisoning. The food hygiene certificate displayed in the kitchen for the chef on duty on the day of the inspection had expired (dated 16/05/05). Training should be provided every 3 years as stated in the certificate. The AQAA was returned to us by the date it was requested. All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the home. The evidence to support the comments made was satisfactory, although there were areas where more supporting evidence would have been useful to illustrate what the home is planning to do so as to improve the quality of service provision. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 25 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 2 x 3 3 3 n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 18 3 2 3 3 3 3 3 3 3 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 3 3 3 X 3 2 2 Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 27 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement A risk assessment must be carried out for residents who are on anticoagulant medicines such as Warfarin so that they are not put at risk. The general décor of the kitchen including the badly stained floorings, sinks and storage areas must be carried be out so that food is stored and prepared in a clean environment. Where an error has been made in recording in residents care plans, sticky labels must not be used to cover the errors. Doors must only be held opened by means approved by the Fire Safety Officer and not wedged so that residents are not put at risk. Food cooked previously and stored in fridge must be labelled and dated to avoid food poisoning. Timescale for action 06/11/09 2. OP19 23 18/12/09 3. OP37 17 06/11/09 4. OP38 23 04/09/09 5. OP38 13 04/09/09 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 Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 28 1. 2. 3. 4. 5. 6. OP1 OP7 OP9 OP19 OP19 OP19 7. OP38 The ‘Statement of Purpose’ and the ‘Service User’s Guide should be updated to provide the correct details of the Commission. Care plans should be signed by the resident of their relatives/representatives. Medicines returned for disposal should be signed by the pharmacist. The fluorescent light in the kitchen should be provided with a cover as required by the Health and Safety procedure. The kitchen should be deep cleaned on a regular basis. Old and broken furniture, bath tub and other building materials left in the front garden should be removed and disposed of so as to compliment the well maintained grounds of the home. Training for staff in food hygiene should be kept up to date. Stanborough Lodge DS0000019585.V377513.R01.S.doc Version 5.2 Page 29 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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