Care Home: Standon Hall Care Home

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What the care home does well There is effective management in place at this home, which has had, and continues to have, a direct effect on improving outcomes for the people who live there. The current Registered Manager has been in place for approximately two years and she is supported by a Clinical Manager who has worked at the home for a similar period of time. They are, in turn, supported by a Regional Manager form the Company who visits the home at least monthly. Managers have worked hard to improve staff training and development and to ensure that the staff who work at the home, including themselves, are equipped with the skills and expertise to meet the needs of individual who live there. The programme of therapeutic activities is geared around meeting individual needs, preferences and abilities. Different people enjoy doing different things and are encouraged to continue and peruse any hobbies and interests they had before entering the home. There has been consistency of managing activities with the co-ordinator having worked at the home for several years. What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Standon Hall Care Home Standon Nr Eccleshall Stafford Staffordshire ST21 6RA Lead Inspector Yvonne Allen Key Unannounced Inspection 24th January 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Standon Hall Care Home DS0000022376.V346221.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. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Standon Hall Care Home Address Standon Nr Eccleshall Stafford Staffordshire ST21 6RA 01782 791555 01782 791396 ejclarke01@hotmail.co.uk 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) Standon Hall Home Limited Mrs Beverley Davies Care Home 25 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9), of places Physical disability (25), Physical disability over 65 years of age (25) Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Minimum age 60 years Date of last inspection 24th May 2006 Brief Description of the Service: Standon Hall is a care home providing personal and nursing care and accommodation for up to 25 service users over the age of 65 years. The home also provides care for up to 2 service users with dementia (over the age of 65 years) and care, including nursing care, for up to 25 service users with physical disabilities over the age of 65 years. A private company known as Standon Hall Home Ltd owns the home. The home is located on the outskirts of the market town of Eccleshall in Staffordshire in the countryside but is not close to shops, pubs or other conveniences The home was built as a stately home several years ago and was first registered as a nursing and residential home on 6/3/96. Service users are accommodated on two floors. The home has 19 single rooms and 3 double rooms, some with ensuite facilities. There are separate assisted baths, showers and toilets. There is a passenger lift and a stair lift. The home has extensive grounds and gardens, which are well maintained and accessible to individuals including wheelchair users. This home has very large spacious communal rooms, most windows having views over the surrounding countryside. The fees charged are available on request from the manager and will also be contained in the Service User Guide. The amount of fees payable will differ depending on individual contribution. The home accepts individuals who are funded (by Social Services or the Health Authority) as well as self-funding residents. Individuals requiring nursing care will also receive an assessment as to the level of free nursing care available to them. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good outcomes. This unannounced inspection was carried out by one inspector and took place over four hours. Prior to the inspection visit the Providers had completed a self-assessment tool known as an Annual Quality Assurance Assessment (AQAA). Information from this AQAA was used to plan the inspection visit. All the Key minimum standards were assessed and judgements were made for each outcome. Each judgement reflects what the home is like for the people who live there. The ways in which we gathered information were as follows – A tour around the home looking at a random selection of bedrooms, all the communal rooms and the kitchen. Discussions with the Registered Manager – Beverley Davies. Examination of relevant records and documentation including a random sample of care plans. Discussions with residents and staff. Observation of care practices. Discussion with a Social Worker who places individuals at the home This was a positive inspection and the home had improved in many areas since the last Key inspection was held. There has been consistency of management at the home over the last 2 years, which has had a positive impact on outcomes for the people who live and work there. We were made to feel welcome by the manager, staff and residents in the home and all were helpful in providing information for the inspection. There was one requirement and two recommendations made as a result of this inspection. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All previous requirments were addressed within the timescale. Particular areas of improvement have been in staff training and development. Thus ensuring that staff understand the needs of individuals – both personal and nursing care, and are able to meet these needs. Staff members spoken to confirmed that they felt there training and development needs were met and that the manager is very supported. Another area of improvement has been in the presentation, quality and variety of the meals provided. The Chef employed at the home is very effective in producing a variety of interesting meals to suit individual needs and preferences. This outcome has been improved for the people who live at the home and residents spoken to were impressed with the meals provided – “The meals here are excellent” and “Lovely meals – no complaints at all”. The Providers have also highlighted the following areas in their AQAA where they feel that they have improved “Activities are changed regularly following suggestions made at the residents/relatives meetings so that the activities plan reflects the preferences of our residents. The most recent change was for the reinstatement of Bingo. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 7 Clients had decided previously not to have this activity due to lack of participation but recently they felt (particulary the ladies) it needed to be reinstated. This has been a roaring success and even some of the men now join in! Clients can be taken to church on Sunday morning if they wish to. Arrangements have been made with the Ladys Fellowship for transportation to and from Standon Church. This has also assisted in the development of relationships in the local community with some clients now attending events at the church and in the community throughout the year. Changes have been made to the menu following feedback from questionnaires and client meetings. Trial of a new four-week menu was commenced and then further responses requested regarding this. As client feedback was positive this menu was then used. A more user-friendly menu was then devised that was easy to read and reflected the meals on a daily basis. We also encourage friends and relatives to share a meal with the residents. The menu also changes to reflect the time of year and service user suggestions are taken into consideration for this as well. The home promotes theme days where certain different dishes are tried. If successful then the most popular can be intergrated into the menu. America Day and Italian Day have been the most recent theme days, Italian being most popular.” “Through senior staff training we ensure that all components of the preadmission assessment are fully completed, leaving no gaps in recording. We are building a closer, more effective liaison with all relevant outside agencies. This has included areas such as the tissue viability service and the palliative care service. As a result of this workshops relating to palliatve care have been planned for December and January and will cover four specific areas including pain and symptom control.” “We have reviewed and updated all policies and procedures. 83 of care staff have completed, or commenced, an NVQ level 2 care course. A nominated link nurse is available within the home with continence care expertise and is included in PCT specialist groups so that the home can benefit from updating in this field. We have developed a good relationship and communication with the GP and we are able to converse openly to ascertain appropraite treatments for clients in order to inprove their health and well-being.” “Changes have been made to the menu following clients views and following completion of service user meal surveys and questionnaires. Theme/taster days have been introduced to encourage clients to try different foods and broaden their taste horizons, with the aim of widening the choice on the menu. Transport to and from the local church has been arranged to allow client choice of having their religious service at Standon Hall or within the church itself. We have developed links with MENCAP to encourage work experience within the home. Future employment may then be gained from local residents which also encourages links within the local community.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 8 “We have reviewed and improved the complaints procedure. All staff have received training relating to safeguarding adults. Care staff have completed, or have commenced NVQ Level 2 in care (currently 83 compliance)”. “Improvements have been made to the fire alarm system following recommendations from the Fire Officer. Locks have been purchased for bedroom doors to allow client choice in relation to privacy and dignity. Staff training has been developed and provided to include NVQ in cleaning services, health and safety, COSHH, moving and handling, NVQ level 2 in care, fire safety training, fire marshal training and infection control. The frequency of fire drills has improved and staff are more aware of their responsibilities in the event of such an incident. The emergency contingency plan has been developed further to include relevant information including the ordance survey co-ordinates of the home due to its rural location. This aids in a swift response from emergency services. Redecoration has occurred in certain areas of the home. This has included the area adjacent to the communal WC on the ground floor, the corridor area between the kitchen and the Administrators office and improvements to the first floor. The shower room has been repainted. Whilst some rooms have darker wallpaper than others this is in keeping with the ambiance of the home and its stately appearance. Domestic staff have completed an NVQ in domestic and cleaning services.” “We have developed and improved our training with the collaboration of Caring Homes training company (Training in Care Ltd). Increased our percentage of staff undertaking NVQ level 2 in care. Developed links within the community to allow work experience to be undertaken at Standon Hall. This will aid with the selection and recruitment for future care staff.” “Management within the home and clients sense of security and enhanced well-being have improved due to the leadership and dedication of the manager. Low care staff turnover has lead to continuity of care provision and has enhanced the relationships between staff, clients and others. We have built on the relationships with other professionals to ensure an open, transparent delivery of care is achieved that maximises client choices and preferences”. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 9 What they could do better: Although some redecoration has taken place since the last inspection this home is in need of updating throughout with many areas now looking worn and tired. This is especially pertinent to bedrooms, toilets and bathrooms. The programme of redecoration and refurbishment should be implemented more quickly in order to improve the appearance and comfort of the environment for the people who live there. The Service User Guide will need to include the level of fees charged by the home so that prospective residents can be fully informed before they make a decision on whether to move in to the home. In their AQAA the Providers have highlighted areas where they feel that they could do better – “We are planning to introduce a Standon Hall Newsletter that can be provided for clients and their families. This will allow families who are unable to attend as often as they would like to be kept informed of all events within the home and to be provided with any forthcoming activities. Clients, who prefer not to attend regular meetings, will have this information as well”. “Although our pre admission forms are indepth and the manager or a trained member of staff visits all prospective service users, some information received is not always up to date and on occasion limits the effectiveness of the assessment. This can be more prevelant when clients are transferring from a hospital as the prospective clients abilities may have been artificially suppressed in those surroundings. We need to be more perceptive when interpreting this information and possibly ask more questions when we have any doubts so that we can be absolutely sure we can successfully meet the needs of the person being assessed.” Although care plans are comprehensive and of a high standard there is always room for improvement. Ensure all drugs are labelled with relevant instructions, although we find GPs can be resistive to this and still produce instructions such as as directed and as prescribed. “Dental care and chiropody treatment is limited in this locale because of shortage of practioners and cost implications. Management are endeavouring to obtain services from local sources but this is proving difficult”. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 10 “To update training to all our staff particularly in relation to Mental Capacity Act and how this affects client care choices. Updated staff training to be provided regarding changes to Tissue Viabilty and changes to prescribing formulary. This session is planned for September. To continue to audit our working practices regarding medication administration (ensuring GP does not produce prescriptions for as directed medications) and care file recording. To continue to source available client services in relation to dental treatment and chirpody.” “Arrange more frequent outings (use of minibus) especially in the warmer weather. Persevere with expanding our relative input at meetings and encourage their participation. Commence use of minibus to enable more frequent outings to local facilities. Develop more community links and investigate bringing younger people into the home from local schools and colleges to share life experiences. This would have to be under strict supervision and with co-operation of supervisors and teachers.” “We could provide the Statement of Purpose and Service User Guide in differing formats to include those clients who are unable to read the current format without assistance. Develop links with voluntary agencies who could provide another avenue of client advocacy. To update training to all our staff particularly in relation to safeguarding adults and the Mental Capacity Act and how this affects client care choices. To develop links with voluntary agencies and increase advocacy service for the clients.” “To improve the frequency of Health and Safety Committee meetings and ask clients or their families if they would like to be included in these meetings. To develop the training provision within the home to ensure compliance with all health and safety requirments. Involve clients and their families in the health and safety aspects of the home by attending health and safety meetings if they wish to. To continue with the redecoration and improvement plan.” “We hope to recruit and enlarge our bank of staff. To develop the training provision further to include specific areas such as palliative care which has been arranged for December/January and tissue viability which has been arranged for September. To also provide training relating to the Mental Capacity Act and how this impacts on client care choices. To facilitate clinical updates for qualified staff as required. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 11 To further develop the links within local organisations to encourage work experience and aid future recruitment.” “We could improve the current level of family involvement in client care issues by rearranging client/relative meetings so that an evening meeting could be made available. Have designated managers surgery hours available, possibly in the evenings, to enhance open communication. Training relating to specific client care needs to be delivered through other professional services. For example, tissue viability training is planned for September and palliative care workshops are planned for December and January. To provide training in relation to Mental Capacity Act paying particular emphasis on client care choices.” 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. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 12 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 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each individual receives an assessment of their needs and can be assured that his or her needs will be met at the home. The Service User Guide will need to include the level of fees charged so that prospective residents are made aware of this. EVIDENCE: We looked at standards 1,3 and 4. We were supplied with the home’s updated copies of the Statement Of Purpose and Service User Guide prior to the inspection visit. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a service user’s guide. The guide details what the prospective residents can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 14 and experience of staff, how to make a complaint, recent CSCI inspection findings and contains comments and experiences of residents living at the home. All residents are given a copy of the guide and placement officers are able to access this also. It is a requirement that information be put into the service user guide in respect of the amount of fees charged by the home so that individuals understand how much they will have to pay towards the cost of their stay. We looked at a random sample of four care plans. Admissions are not made to the home until a full needs assessment has been undertaken. For people who are self-funding and without a care management assessment, a skilled and experienced member of staff always undertakes an assessment. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. These were seen contained in the care plans. Discussions with the registered manager identified that admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Discussions with a Social Worker responsible for placing individuals at this home identified that she was pleased with the home and how this had improved. She was happy with the care and services provided to her clients. In their AQAA the Providers state – “The home has excellent links with both Social Services & the NHS funding team. Prior to admission in-depth, comprehensive reports are obtained. Significant time end effort is taken so that that these reports, along with our own pre-admission assessment policy, ensures that all prospective clients are given information about the home and are re-assured that their needs can be fully met. This information is given at the pre-admission visit undertaken by the manager or senior member of staff. All clients receive this type of visit before admission. Family members also provide details relating to the prospective clients. Prospective clients are encouraged to visit the home and spend some time meeting other clients, meeting the staff and generally soak up the atmosphere of the home. Clear information relating to contract terms and conditions is provided including the trail period offered. Fees and other charges are also given. These are included within the Service User Guide and Statement of Purpose which is given to all prospective clients and their families. Leaflets from SAGA and Symponia are available for privately funded clients highlighting services relating to long-term management of finances. (Although the home does not endorse these services, positive feedback has been received regarding them). Staff are skilled in care provision and training is regularly updated to ensure that the care they provide is of a high standard and relevant to the service. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 15 The care staff turnover at Standon Hall is low so staff have built up excellent relationships with the clients and their families. They are aware of all aspects of each clients individual care needs and are vigilant to changes. All staff receive briefing regarding any new client and a full needs assessed care plan is implemented. All clients receive the same pre-admission assessment and attention to detail relating to their individual care files regardless of funding arrangements.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual has a plan of care in place and personal and nursing care is delivered with dignity and respect. Health care needs are monitored and met and individuals are helped to maintain independence wherever possible. EVIDENCE: We looked at standards 7,8,9 and 10. We examined four care plans and spoke to residents and staff members. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred. Staff respect privacy and dignity and are sensitive to changing needs. Staff were seen and heard speaking to individuals in a respectful manner. People are supported and helped to be independent and can take responsibility for their personal care needs. Records examined evidenced that residents have access to healthcare and remedial services. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 17 Staff make sure that those who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. At the time of the inspection visit, the manager had taken one of the residents down to the surgery for a blood test. The health care needs of residents unable to leave the home are managed by visits from local health care services. Residents have the aids and equipment they need and these are well maintained to support them and staff in daily living. Staff have access to training in health care matters and are encouraged and given time to attend seminars on specialist areas of work. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. The medication procedure was examined and discussions were held with the nurse in charge. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. The home respects and understands the rights of residents in the area of health care and medication. They work with individuals regarding any refusal to take medication. Residents are given the support they need to manage their medication id they wish and are able to and following a satisfactory risk assessment. We were informed that there was no one self-medicating at the time of the inspection. The home has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. Only trained nurses administer medication. Staff work to clear and robust practices when caring for individuals who have degenerative conditions and terminal illnesses. Care plans are person centred and contain clear information about the individual’s wishes, choices and decisions as their health deteriorates. Nursing and care staff work to a very high consistent standard and constantly monitor pain, distress and other symptoms to ensure individuals receive the care they need. In their AQAA the Providers state – “We have comprehensively assessed working care plans that instruct all levels of staff on how to look after clients and to ensure that all their assessed needs are met. Individualised Care Plans are clear and comprehensive, of good quality and are reviewed at least monthly by the trained staff. A quality auditing system is in place to ensure that this is maintained and the content relevant and accurate for each client. Feedback is also gained through our service user questionnaires and regular client/relative meetings. However, all clients are Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 18 encouraged to discuss and express their needs on an on-going basis. An open door policy is in operation and all clients and family members benefit from this personal service. Clients and their families are encouraged to participate in the care process and provide feedback on the care provision received. We have a strong ethos of involving all clients in every aspect of their care and this is evident within the plans written and through discussion with the clients. Where family involvement in care is not available an advocacy service can be contacted. Details regarding this service is displayed within the home and details given to new clients on admission. Each client has comprehensive risk assessments completed that are monitored continuously and reviewed regularly. These take into account the clients ability and their aspired level of independance. Clients are encouraged to be as independant as possible. This has a positive effect on the client and ensures optimum self esteem and dignity. Clients have full access to outside healthcare professionals of their choice. For example, through discussions with their GP they are able to state which hospital they wish care to be undertaken. Clients are encouraged, where possible, to retain all previous healthcare professionals involved in their care prior to admission and optimise continuity. This allows for a greater understanding of the clients particular care needs. If this is not possible staff discuss the options available with the client to ensure that the correct services are sought. Our system for storage and administration of medications is robust and all aspects from ordering to administration is checked regularly. Trained nurses are responsible for administration and recording of medication. A quality assurance auditing system is in place that monitors if this is carried out effectively and accurately. Full communication between staff and the GP is undertaken to ensure that all medications given are appropriate and effective. However, GP can still provide medications with use as directed instructions at times. Staff ensure that these instructions are altered to reflect specific instructions. Staff have undertaken medication competency assessments and their working practice is regularly reviewed by management. The home has a sustained record of compliance with the receipt of medications and the administration, safekeeping and disposal of medications. All records relating to client care provision and associated forms comply with, and are maintained at, ISO 9001 standard. Staff respect residents and strive to maintain their dignity by always asking and consulting with them about their preferences plus ensuring that all personal care is given in privacy. Staff attitudes and working practice is monitored daily by management and client views regarding this area are sought. Formal staff supervsion sessions are undertaken. Over 80 of care staff have completed, or are completing, an NVQ level 2 qualification in care. This highlights our commitment to maintaining and improving client care provision at Standon Hall.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 19 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Daily life including meals and social activities are geared around meeting the preferences, abilities and needs of the people who live in the home. EVIDENCE: We looked at standards 12,13,14 and 15. People who use the service have the opportunity to develop and maintain important personal and family relationships. Visitors were observed during the visit and are able to come and go at anytime of the day. Families and friends are encouraged to become actively involved in the life of the home such as helping with activities and trips out and attending meetings. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. There was evidence of this in all the care plans. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 21 The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. Care plans contained records of life histories and preferences in respect of activities. Residents can access and enjoy the opportunities available in their local community including the mobile library, which was visiting at the time of the inspection visit – much to the joy of one of the residents who was eagerly waiting to change his books. Another resident showed us his photographs from his days as a fisherman and he also enjoyed tending to his plants outdoors and going off to visit his relative who lived down the road – this was accessible to him via his electric wheelchair and a ramp provided by the front entrance. The service has benefited from an activities co-ordinator who has worked at the home for many years. She is enthusiastic and motivated and it was obvious that the residents hold her in high esteem. The service also benefits from a very experienced and efficient Chef who has brought about considerable improvements in the presentation and variety of the meals served. The menu is varied with a number of choices including a healthy option. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They were observed helping individuals with their lunchtime meal and are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. It was disappointing, however, to observe the low stock of foodstuffs stored at the home in the cupboards refrigerators and freezers and when asked about this we were informed that it was delivery day and that stock would be replenished by the end of the day. It was still a matter of concern, however, as should the delivery be late or not arrive there would be very limited stock to prepare meals with for any length of time. In their AQAA the Providers state – “The emphasis within our policies and procedures is to include clients in their daily lives and routines as much as possible. Their views are respected and their choices adhered to. We have a designated activities co-ordinator who seeks out client views and suggestions regarding specific activities they may wish to undertake in collaboration with the clients keyworker. This is performed through daily interaction and conversations as well as through client and relative meetings. Client preferences relating to their social activities is maintained and updated as their needs or views change. An example of this Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 22 was with the reintroduction of Bingo to the activities calender recently. Prior to this clients had chosen to remove it from the calender due to lack of participation. With the admission of new clients participation has now increased and it is one of the more popular activities. Activites and social occasions are recorded for all clients within their individual care files. All clients have biographical information gathered as part of their assessment so that activities can be planned to incorporate their preferences and former interests. Where this information was scant, letters were sent to relatives to ask for more information about their loved ones previous interests so that we could provide social and leisure pursuits relevant to them from the past. Forthcoming activities are displayed on the notice board within the reception area. Minutes of client/relative meetings are available within the managers office (Meetings file). The latest is also displayed on the notice board within the reception area. Statement of Purpose and Service User Guide is displayed on the main notice board. All clients have also received a copy of this. Records relating to client financial affairs is maintained. Personal allowance accounts are maintained for all clients and records are available for inspection at any time. All staff actively listen to and respond to client requests regarding the running of the home. The manager maintains an open door policy that makes clients and their families feel at ease discussing issues personal to them. Clients are encouraged to maintain family ties and links with the local community where possible. Arrangements have been made with the local church to transport any clients wishing to attend Sunday services at the church. Most clients still choose to have their religious service provided at the home but one client in particular always visits the church on a weekly basis. Clients are also encouraged to participate in any of the local events offered through the church or other establishments. We have regular religious services at the home from Church of England and Catholic ministers. Clients seeking spiritual or religious guidance with differing faiths are provided for as required. At present we have one client at Standon Hall who follows the Jehovahs Witness faith. This client receives regular visits from his minister at Kingdom Hall. Specific instructions and needs required by this client in relation to his beliefs are recorded within his individual care file. Families are encouraged to continue to take their loved ones on outings as they would have done prior to admission. Risk assessments relating to this are completed and maintained with the collaboration of family members. Regular reviews of these assessments are undertaken and also reviewed as needs change. Staff are available, and willingly volunteer, to undertake escort duty should this be required. The activities co-ordinator endeavours to provide regular entertainers to the home. This is particularly beneficial to clients who may be unable to participate in group activities due to their care needs. One-to-one activities are also Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 23 provided to clients. This includes hand massage sessions, reading of books and conversing about life experiences. Visitors are welcome at any time and meals, drinks and snacks are available to visitors to enable them to visit for longer periods if they so choose. Clients can choose to entertain visitors in the privacy of their own room or by using one of our three spacious lounge areas. There are also extensive grounds overlooking fields and local farmland with seating provision should clients and families wish to enjoy these views and watch the wildlife this area has to offer. We encourage families to celebrate special occasions with their loved ones. (We recently had a gentleman who enjoyed his 100th birthday and the lavish celebrations provided between ourselves and his extended family). Food is considered to be highly important and mealtimes are seen as an intergral part of the social calender. The meals are produced by a highly qualified and experienced Chef who is aware of each clients personal perferences and specific medical dietary requirements. Changes have been made to the menu recently following feedback from questionnaires and with the Chef discussing preferences with the clients. Trial of a new four-week menu was commenced and then further responses requested regarding this. As client feedback was positive the menu was then implemented. A more user-friendly menu was then devised that was easy to read and reflected the meals on a daily basis. We also encourage friends and relatives to share a meal with the residents. The menu also changes to reflect the time of year and special events such as Christmas. Meals produced are nutritious and very well presented and we get positive comments from both clients and visitors. A choice of menu is available at each meal. If clients do not like the choices on the menu the Chef will endeavour to provide the client with an alternative of their chosing. The home has theme days where certain different dishes are tried. (This encourages clients to try different foods and tastes). If successful then the most popular can be intergrated into the menu. America Day and Italian Day have been the most recent theme days, Italian being the most popular. Where assistance is required to enable clients to acheive an optimum level of dietary intake, staff are available to perform this task in a sensitive and helpful manner. Mealtimes are relaxed and clients are given time to enjoy their meals at the pace appropriate to them. Clients can choose to have their meals in their own room, in the lounge or within the comfortable dining room. Clients may be encouraged by staff to have their meals in the dining room on some occasions due to the social nature of mealtimes. If clients choose to have their meals at differing times, the Chef will make provision for this and provide a meal at the chosen time. We have recently achieved the Hospitality Assuarance Award. We have no fixed rising times and clients retire at their request. Routines are flexible to allow for client personal choice and preference. These routines can be altered quickly if changes in client care needs is observed. We encourage service users to personalise their rooms to enhance the homely feeling. Where clients are unable to choose, or have limited personal items, staff endeavour to provide items to enhance the homely atmosphere. This is usually undertaken by the clients keyworker. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 24 Where possible clients are encouraged to take responsibility for their own financial affairs. They are able to use their money for whatever they wish. Clients are escorted on shopping trips by staff if family members cannot offer this service. For those clients not wishing to go shopping for themselves, or are unable to go shopping for themselves, staff will perform this task for them. The activities co-ordinator also maintains a shopping trolley where clients can purchase toiletry items, stationary items and confectionery. Clothing parties are arranged every few months to coincide with changing seasons and specific events such as Christmas. The local pharmacy and lingerie shop have also had events at the home where clients (and their families) were able to purchase goods in the comfort of their own home.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home can be assured that the systems in place will help to keep them safe and that any concerns they might have about the home will be listened to and taken seriously. EVIDENCE: We looked at standards 16 and 17. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with the service provided, feel safe and well supported by an organisation that has their protection and safety as a priority. Minutes of residents/relatives meetings were seen where individuals are given an opportunity to air any concerns and service user surveys are carried out from time to time. The manager explained that she has adopted an open door policy and that residents or relatives will often visit the office and chat to her an a one to one basis. We saw evidence of this during the inspection visit. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 26 The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats (including other languages, large print, audio etc) to help anyone living at, or involved with, the service to complain or make suggestions for improvement. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The home learns from complaints, and it is rare that a complaint about the same issue is made twice. Three residents spoken to confirmed that they knew who to go to should they have any concerns. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them (Staffordshire Intra-Agency Vulnerable Adults Policy). Two staff members spoken to knew how to report suspected abuse and the manager knows when incidents needed external input and who to refer the incident to. There is a clear system for staff to report concerns about colleagues and managers. Staff that ‘blow the whistle’ on bad practice are supported by the service. The home has a history of following the procedures for safeguarding adults and the manager will always attend meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The outcomes from any referral are managed well and issues resolved to the satisfaction of all involved. Training of staff in safeguarding is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. Examination of staff training files confirmed this. The staff spoken to understand what restraint is and alternatives to its use in any form are always looked for. Equipment that may be used to restrain individuals such as bed rails, keypads, recliner chairs and wheelchair belts are only used when necessary. People are involved in the decision making process about any limitations to their choice in this area. Individual assessments are always completed which involve the individual where possible, their representatives and any other professionals such as the care manager or GP. Evidence of this was seen contained within individual care plans. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 27 The Providers state in their AQAA – “Standon Hall has a clear, concise complaints procedure that is prominently displayed, robust and easy to follow. Full details are also recorded within the Service User Guide. Clients are activley encouraged to complain about the service provision should they find it inadequate for their needs. Clients and their families are also encouraged to make suggestions on how the service can be improved. Clients are aware of who to complain to should they feel this is necessary. The manager operates an open door policy and this makes it easier for clients and family members to feel at ease discussing anything they feel is appropraite to them. It also prevents minor problems from escalating. There is also a whistle-blowing policy prominently displayed should anyone feel that this is a necessary course of action. Any complaint is dealt with immediately to ensure that all parties are confident that their complaint is taken seriously and acted upon. Full records are maintained and all interested parties are informed of the outcomes within a 28-day period. An action plan is devised that highlights any requirements to prevent the repetition of the complaint. All staff are then made aware of any changes to current practice if necessary. Should a complaint be made that requires the involvement of other services (GP, CSCI, local adult protection teams) these are informed immediately and open and honest discussions take place to clarify steps to be taken and decisions to be made. We ensure that all staff comply with the policies and procedures relating to client protection and the safeguarding of adults policy. This is achieved through training, clinical supervision and the monitoring of working practices. All clients state that they feel safe and secure and are supported by the manager, clinical manager and the care team. This is evidenced in the recent service user questionnaire and through discussions with clients and their families. All staff are assessed and verified by the Criminal Records Bureau before commencement of employement. Clients are encouraged, where possible, to maintain the right to vote in local or general elections. Some clients refuse to participate in this process but others do take up to option to use the postal voting system. Advocates are encouraged when family involvement is limited. Details of this service are displayed within the home and also within the Service User Guide. Clients are encouraged if possible to maintain links with the local church and attend services when they wish to.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a clean and safe environment, which is spacious and has character. This outcome would be improved by redecoration, refurbishment and updating of the home. EVIDENCE: We looked at standards 19 and 26. We walked around the home and inspected all the lounges, dining room, kitchen and a random sample of bedrooms. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 29 The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable and has a programme to improve the decoration, fixtures and fittings. However redecoration and refurbishment has been minimal at the home with bedrooms, bathrooms and toilets looking tired and worn and furniture and carpets in need of replacement. It was observed that work was in progress in the kitchen as per redecoration plan. We were informed that a bed/mattress replacement programme is in place and evidence of new beds was seen at the time. Residents can personalise their rooms and evidence of this was seen. They also say they the home is clean, warm, well lit and there is usually sufficient hot water. Some en-suite facilities are available and bathrooms are accessible to all people in the home. Toilets are appropriately located within the home, are easily accessible and in sufficient numbers. The communal rooms are large, spacious and grand and residents were observed making use of all these areas at the time of the visit. The dining room was pleasantly presented and the majority of residents eat their meals here, although they have the choice of taking meals in their own rooms also. Maintenance is on going at the home with a full time maintenance person employed to work between the two homes on the site. The Providers states on their AQAA – “We encourage clients to see Standon Hall as their home. All necessary adaptions required to meet specific client care needs are provided. These include hoists, chairlifts, a passenger lift and variable height beds. This allows clients to maintain an optimum level of independance within the home. Full servicing records of all adaptions are maintained. The home meets the requirements of the Disability Discrimination Act and is applicable to the needs of the client group. Standon Hall is stately in manner and has extensive grounds. The grounds are well maintained and are easily accessible to clients via the main entrance. A ramp has been fitted to this entrance to maximise accessibilty. There are three large communal lounges, one of which overlooks the magnificent countryside views. Another lounge is used primarily for activities, whilst the reception lounge is used for a more contemplative, quiet area. The dining room is large and spacious and offers a relaxed atmosphere to dine. Clients are able to entertain their guests in any of the communal lounges or within their own rooms. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 30 All of the communal areas are large and well exceed the minimum standards for clients living at Standon Hall. Many original features such as fireplaces, oak paneling and ornate plasterwork make Standon Hall a lovely place to stay. All bedrooms exceed the minimum standard required for size. Most rooms are single rooms with several benefiting from ensuite facilities. There are three double rooms at Standon Hall. Clients and their families can choose if they wish to accomodate a single or double room. This is especially beneficial if a married couple wish to live at Standon Hall. Clients that do share a room are provided with screens to ensure their privacy is maintained. At present only one double room is occupied by two clients and this was an expressed request from family as the married couple had not lived apart for 60 years. This situation is reviewed regularly by staff and family members. All bedrooms are comfortable and exceed average size. A replacement bed programme is currently being undertaken due to the extended life of the existing beds. Clients are able to choose if they wish to have a lock on their bedroom door to maximise privacy. New clients are also asked for their preference and should a lock be required this is adhered to. The nurse call system is maintained and serviced accordingly. These are strategically placed for easy accessibilty by clients. Staff attend promptly to any call for assistance. Communal bathrooms are large and adaptive baths are available. There is also a walk-in shower available for clients who prefer this option. There is plenty of hot running water and the temperature is maintained within required health and safety levels. Records of water temperatures, maintenance of the heating system and boilers are well maintained. The home is clean and tidy and smells fresh. An effective laundry system is in place. Domestic and laundry staff have completed NVQ level 1 in cleaning services and housekeeping. All staff have received training in relation to infection control. Clinical waste is disposed of correctly and working practices ensure that cross-contamination is minimised. Annual visits from Environmental Health are carried out and any requirements made are actioned. No requirements were made at the last visit. A full fire risk assessment is maintained and any remedial work required following a Fire Officer visit is actioned. An emergency contingency plan is maintained and updated accordingly. All general risk assessments are reviewed annually. The Health and Safety Committee meet regularly to discuss issues and plan action accordingly.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 31 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at this home are cared for by a trained staff team who are equipped with the skills to meet their needs. EVIDENCE: People spoken to intimated that they have confidence in the staff who care for them. “ All the staff here are very kind” and “Its wonderful here – I couldn’t be looked after any better”. Examination of the staff rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. At the time of the inspection visit there were 16 residents accommodated – 5 in receipt of nursing care and 11 receiving personal care (residential). On duty was 1 nurse and 2 care assistants all day then 1 nurse and 1 care assistant at night. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 32 Ancillary staff were provided - a housekeeper and domestic staff and a chef together with 2 kitchen porters between the two homes on site. There was a full time maintenance and activities person employed between both homes. The Registered Manager worked supernumery and acted as General Manager over both homes There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for residents and is not led by staff requirements. Examination of staff files identified that staff members undertake external qualifications beyond the basic requirements. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Examination of three staff recruitment files identified that accurate job descriptions and specifications clearly define the roles and responsibilities of staff. All staff receive relevant training that is focussed on delivering improved outcomes for residents. The home puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people in a person centred way. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Discussions with two staff members identified that the home was clear about what was involved at all stages of recruitment and was robust in following its procedure. There are clear contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff. Staff meetings take place regularly and minutes were seen. Three staff files identified that was evidence that staff supervision sessions are regular and staff spoken to said that they find them helpful with a focus on improving outcomes for people using the service. Notes and action points are taken of meetings and sessions, and progress is regularly reviewing. The Providers state on their AQAA – “We ensure that a fully robust recruitment procedure is maintained and staff are recruited to enhance the care provision delivered at the home. Each member of staff has a clearly defined job description and this highlights their responsibilities within the team. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 33 Standon Hall has a strong ethos of staff training and development in order to maximise care provision within the home. All new staff members complete a full induction that includes all areas relevant to client care and health and safety issues. This is developed during their employment and relevant training is provided on an on-going basis. Staff are also encouraged to attain external qualifications to further their personal development as well as optimise care for the clients. We encourage all care staff to complete an NVQ level 2 in care. All permanent care staff have completed, or have commenced, this training. We have a regional training manager through our training company (Training in Care Ltd.) who assists the manager in facilitating training through in-house sessions or by sourcing external courses. The manager and clinical manager have recently achieved a recognised teaching qualification that will assist in the development of further training within the home. They, along with another member of staff, are also recognised moving and handling trainers. The clinical manager is the continence link nurse for the home and is able to cascade information relating to this area of expertise. There are also six members of staff who have been trained as fire marshals. Care staff are provided in the number and skill mix relevant to the needs of individual clients. Staff are committed and dedicated to the clients. Ancillary staff are provided in the number and expertise relevant to the client group.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 34 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed in the best interest of the people who live there. EVIDENCE: The Providers stat5e in their AQAA – “Resident/relative meetings are held at quarterly intervals and all suggestions are listened to and acted upon where relevant. Minutes of these meetings are provided to all clients and is also displayed in the reception area. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 35 Clients and their relatives receive annual questionnaires and are asked questions relating to care provision, meals and social care and how they think these are delivered. They are asked to complete these in confidence and return them directly to our Quality Assurance department for evaluation. The results are audited and expected outcomes are given. The home is then informed of the standard reached and is then required to action any improvements that have been identified. In-house service user questionnaires are also used. These do not go to our Quality Assurance department but assist the manager with the monitoring of the care provision, meals and other services provided within the home. A comments box is available to relatives and clients to allow them to express their opinions anonymously if they so wish. Daily interaction with clients and their families ensures that open communication is encouraged and maintained. By buidling relationships in this way clients are able to express themselves freely in the knowledge that they will be listened to and their views respected and actioned upon.” We looked at standards 31,32,33,35,36 and 38. We spoke with several residents and staff members and examined records relating to staff supervision, quality assurance, maintenance of personal allowances and health and safety. The manager has the required qualifications and experience and is competent to run the home. She provided examples of where she continues to develop her skills and knowledge in order to meet the needs of the people who live at the home. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Her practice, skills, and knowledge, is based on continuous development, gained through training and enthusiasm for the role. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. She works to continuously improve services within her limitations. She provides an increased quality of life for residents especially in the areas of dignity, respect and fairness. There is also a focus on person centred thinking, with residents shaping service delivery. There is a strong ethos of being open and transparent in all areas of running of the home. The individual residents spoken to all confirmed that they felt supported by the manager and that they could approach her at any time. She was also observed as having an easy rapport with the residents and knew them all. Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 36 The manager leads and supports a strong staff team who have been recruited and trained to a high standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. Staff were also complimentary about the manager and stated that they too felt supported by her. The AQAA contains clear, relevant information that is supported by a wide range of evidence. The AQAA lets us know about changes they have made and where they still need to make improvements. It shows clearly how they are going to do this. The data section of the AQAA is accurately and fully completed. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. The manager ensures staff follow the policies and procedures of the home and of the organisation. There are effective systems to monitor staff adherence to policies and procedures during their practice. Management processes ensure that staff receive feedback on their work. This was noted on examination of staff supervision records. The home works to a clear health and safety policy. All staff are fully aware of the policy and are trained to put theory into practice. Regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. Records relating to health and safety confirmed what staff said. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. There is also evidence of organisational monitoring by corporate providers. Records are of a good standard and are routinely completed. The manager ensures risk assessments involve the residents in their production and that they are fully completed and taken into account in planning the care and routines of the home. People are supported to manage their own money where possible. Where this is not possible there is a clear reason why. Individuals have access to their records whenever they wish. The home has access to professional business and financial advice and has all the necessary insurance cover to enable it to fulfil any loss or legal liabilities. The Providers state in their AQAA – “Standon Hall is a privately owned care home within the Caring Homes Group providing personal and nursing care to clients over 65 years of age. The registered manager at Standon Hall has been in post for over two years and Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 37 has the relevant expertise to manage the home effectively providing good value for money. The manager is able to provide strong leadership and support to her team to ensure high standards of client care are achieved. She is committed to ensuring that the health and welfare of the clients is optimised. She is supported in her role by a highly experienced Regional Manager who visits the home at least monthly. There is a recognised support network within Caring Homes that assists the manager in any aspect of her role. The manager has built up excellent relationships with other professionals and members of the multi-disciplinary team to enhance the care delivery at Standon Hall. This has resulted in treatments being provided that are appropriate and effective for individual client needs. The manager attends regular care providers meetings. This provides the manager with information relating to client care issues and therefore she is able to implement change quickly and effectively if required. This has also assisted in optimising the profile of the home. At a recent dementia care meeting Standon Hall was the only representation from the private care sector. The manager operates an open-door policy that has improved communication between clients and their families and the staff. Clients are encouraged to take an active role in the running of the home and make choices to enhance their own lifestyles. Client/relative meetings are held every three months. The manager ensures that working practices are monitored and that policies and procedures are implemented and adhered to. The quality assurance audits performed provides evidence that this is maintained. These include areas such as medication administration, care planning, Service User Questionnaires, meal surveys and catering audits. The home has achieved ISO 9001 status and has also achieved a Hospitality Assurance Award. The manager ensures that staff have received the training relevant to the needs of individual clients. She also attends training regularly to enhance her knowledge and leads by example. She has recently completed a teaching qualification along with the clinical manager. The manager is also an NVQ assessor, moving and handling co-ordinator and has completed fire marshal training. Quality assurance audits are also carried out by the regional training manager relating to training to ensure compliance and relevance. The manager ensures that a clear, transparent audit trail is available in relation to individual client finances. The manager is supported in this role by the Administrator. All records are available and can be viewed by clients at any time. Clients who are able to manage their own financial affairs are encouraged and supported to do so. Insurance certification is current and valid.” Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 38 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 39 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 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 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 x 3 3 x 3 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 40 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 OP1 Regulation 5(1)(b) Requirement It is a requirement that information be put into the service user guide in respect of the amount of fees charged by the home so that individuals understand how much they will have to pay towards the cost of their stay. Timescale for action 24/03/08 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 Provider should ensure that the programme of redecoration and refurbishment is stepped up in order to improve and update the environment especially in respect of bedrooms, bathrooms and toilets. The provider should ensure that there is an adequate stock of foodstuffs maintained at all times in order to have sufficient in case of failure of deliveries and emergency situations. 2 OP15 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 41 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Standon Hall Care Home DS0000022376.V346221.R01.S.doc Version 5.2 Page 42 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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