Care Home: Stoneleigh House

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• Chirnside House
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What the care home does well The management team ensure that prospective service users receive an appropriate assessment to make sure that the facilities and staff skills at Stoneleigh can meet the identified needs of the individual. Staff are kept well informed of the changing needs of service users and communication between staff and family members is good. Service users have access to the full range of medical services available in the community. Service users have their privacy and dignity maintained. Work in conjunction with life story project workers helped to reinforce the individuality of service users. Relatives are made to feel welcome when visiting the home by the approach and attitude of the staff team. The provision of food at the home is very good. Service users believe they can air their views and that they are listened to. Service users also feel protected from abuse or exploitation. Staff have access to training opportunities to ensure that they remain competent to undertake the tasks required of them. Staff told us that they felt supported by their approachable and helpful colleagues and managers. All service users and relatives with whom we had contact during this key inspection spoke positively about their experience at Stoneleigh. One visitor cited, as among the best things about the home, the staff, who were "very pleasant and friendly comfortable when you come in" and said "it`s mum’s home". Another relative said "I can`t honestly fault the place" and, "I’ve booked a room, I`d have no qualms about being here." another relative cited as among the best things the "welcoming, relaxed atmosphere." What has improved since the last inspection? Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 The requirements identified at the last key inspection in June 2009 had all been addressed. This included an improved process for the risk assessment and management of falls and the implementation of a more robust system for the recruitment and vetting of new staff. What the care home could do better: Records relating to the application of prescribed creams, must be maintained with the same degree of thoroughness as any other medication. This is to ensure that prescribed remedies are being administered appropriately. Any directions given in connection with medication timing, such as a specific time before food, must be followed and the medication administration records must confirm this. The provision of activities could be improved. This was well understood by the manager who was actively working to recruit a dedicated member of staff. Quality assurance questionnaires and feedback from service users must be reported on in writing. A copy of that report must be made available to service users and the Care Quality Commission. Key inspection report CARE HOMES FOR OLDER PEOPLE Stoneleigh House Cooper Street Springhead Oldham OL4 4QS Lead Inspector Steve Chick Key Unannounced Inspection 10:00 3 and 5 November 2009 rd th DS0000005521.V378140.R01.S.do c Version 5.3 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. Stoneleigh House DS0000005521.V378140.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 Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoneleigh House Address Cooper Street Springhead Oldham OL4 4QS 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) 0161 624 5983 0161 678 2158 stoneleighhouse@masterpalm.co.uk Masterpalm Properties Limited Miss Diane Riley Care Home 31 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (23) of places Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, (maximum number of places: 23) Dementia over 65 years of age - Code DE (E) (maximum number of places: 8) The maximum number of people who can be accommodated is: 31 Date of last inspection 22nd June 2009 Brief Description of the Service: Stoneleigh House is a detached property in a semi-rural location. It is situated close to public transport and local amenities. To access the property, people have to manage a small incline from the main road. The outside of the property is well maintained, with landscaped gardens and views over the local area. Accommodation is provided in 27 single rooms, 26 of which have en-suite facilities. There are two shared rooms, both of which have en-suite facilities. Communal areas include three large lounges, one of which is an allocated smoking area, and a large dining room. Information about the home can be obtained from the Service Users Guide, which is a booklet which contains details of what people could expect from the service. Alternatively, information can be obtained from the manager, in person or by telephone. Fees charged are £390.00 per week. Stoneleigh House DS0000005521.V378140.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 one star. This means the people who use this service experience adequate quality outcomes. We (the Care Quality Commission) undertook a key inspection, which included an unannounced visit to the home. This meant that no one at Stoneleigh knew that the visit was going to take place. We returned on the second day by appointment to talk to service users and any relatives who were visiting. All the key inspection standards were assessed at the site visits. For the purpose of this inspection two service users were interviewed in private, as were three relatives of service users and three staff members. Additionally discussions took place with the manager and a senior member of staff. Surveys for service users, relatives and staff were left at the home for distribution on the second day of the visit. At the time of writing this report, we had received completed surveys from four service users (all of whom were helped to complete the survey), one relative and seven staff members. We also looked at information we have about how the service has managed any complaints, what the service has told us about things that have happened in the service, these are called notifications and any relevant information from other organisations. We had also asked the management of the home to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA). This is a legal requirement. The AQAA was provided as requested in June 2009 and told us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, some of these comments have been included in the report. We undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. We have not received any complaints or allegations about the service since our last Key Inspection. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 Page 6 What the service does well: The management team ensure that prospective service users receive an appropriate assessment to make sure that the facilities and staff skills at Stoneleigh can meet the identified needs of the individual. Staff are kept well informed of the changing needs of service users and communication between staff and family members is good. Service users have access to the full range of medical services available in the community. Service users have their privacy and dignity maintained. Work in conjunction with life story project workers helped to reinforce the individuality of service users. Relatives are made to feel welcome when visiting the home by the approach and attitude of the staff team. The provision of food at the home is very good. Service users believe they can air their views and that they are listened to. Service users also feel protected from abuse or exploitation. Staff have access to training opportunities to ensure that they remain competent to undertake the tasks required of them. Staff told us that they felt supported by their approachable and helpful colleagues and managers. All service users and relatives with whom we had contact during this key inspection spoke positively about their experience at Stoneleigh. One visitor cited, as among the best things about the home, the staff, who were very pleasant and friendly comfortable when you come in and said its mum’s home. Another relative said I cant honestly fault the place and, I’ve booked a room, Id have no qualms about being here. another relative cited as among the best things the welcoming, relaxed atmosphere. What has improved since the last inspection? Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 Page 7 The requirements identified at the last key inspection in June 2009 had all been addressed. This included an improved process for the risk assessment and management of falls and the implementation of a more robust system for the recruitment and vetting of new staff. What they could do better: 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. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 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. Service users’ needs are assessed before moving to the home to ensure that their needs can be appropriately met. EVIDENCE: The manager had told us in the AQAA that preadmission assessments were undertaken by the home, other than in an emergency placement. We looked at a small selection of service users files. Preadmission assessments were seen. There was also documentary evidence that in an emergency placement, a care plan had been written within 48 hours. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 10 All relatives and service users who we asked, told us that staff from the home had met with them to undertake an assessment before a decision was made to move to the home. One relative told us they had visited several care homes before deciding on Stoneleigh. Another confirmed that their relative was reassessed by staff at the home following an admission to hospital. Stoneleigh does not offer intermediate care. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. 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. Service users’ health, personal and social care needs are predominantly met by the implementation of policies and procedures. However, it is not always possible for the home to demonstrate that medication had been given correctly. Staff practices serve to promote the dignity of the service users. EVIDENCE: The manager had told us in the AQAA that service users had individualised plans of care which were periodically reviewed. We looked at a selection of service users’ files, all of which had a copy of a written care plan. Since the previous inspection, risk assessments had been incorporated into the care Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 12 planning process. There was also evidence that nutritional assessments were routinely undertaken. There was also documentary evidence that, where appropriate, the care planning and monitoring process was altered to reflect the level of risk identified for an individual. Staff who we spoke to, told us that the written information in the care plans was complemented by a verbal update on the progress of each service user at each change of shift. Staff were confident that these procedures, in connection with their personal knowledge of the individual service users, gave them sufficient information to provide appropriate, individualised care. All staff who returned a survey to us said that they were always given up-todate information about the needs of the people they supported. All staff who returned surveys also said that the way in which information about service users was shared worked well, either always (5) or usually (2). Relatives and service users who we asked, told us that they were involved in discussions about the way in which care was delivered. We were also told by relatives that there was good communication between staff and themselves. One relative told us (in a survey) “If we ask for anything we need for dad the staff are always ready to help and report back to us.” All service users who returned a survey to us said that staff always listened to them and acted on what they said. There was good documentary evidence that service users have access to the full range of medical services available in the community. All service users, relatives and staff who we asked, were confident that medical attention was sought when necessary and in a timely manner. Medication presented as being appropriately and securely stored. There was a dedicated refrigerator for medication which needed to be stored in a cool temperature. The record of this fridge’s temperature was, in practice, a record of the fridge setting, as, we were told, the thermometer was difficult to access and read. Whilst, at the time of this visit, the fridge did seem to be maintained at the appropriate temperature, it was recommended that a more suitable thermometer should be provided. A small selection of medication administration records was looked at. These generally presented as being appropriately maintained to demonstrate that the correct person was getting the correct medication in the correct dose at the correct time. One example was seen where a specific medication needed to be given between half or one hour before meals. This direction did not appear to have been picked up or acted upon by staff. Records of the administration of prescribed creams were available, but several were seen to be poorly completed. Discussion with staff members indicated Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 13 that this was a failure to complete the records, rather than a failure to administer the cream. During the tour of the building some prescribed creams were seen in communal bathrooms. It was reported by the staff member showing us round that this was due to a failure to return the cream to the service users’ bedroom following a bath and was not normal practice. All service users who we asked told us that they were treated with respect and that their dignity and privacy were maintained by the staff team. One service user told us that the staff were nice and thoughtful and kind and that their privacy and dignity was maintained 100 . Staff and relatives who we asked, also spoke positively about this aspect of the care provided at Stoneleigh. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 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): 12, 13, 14 and 15. 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. Appropriate social contacts and activities are usually facilitated within the home to give service users the opportunity for social fulfilment. The provision of food to maintain service users’ health and well being is good. EVIDENCE: The manager told us that since the previous key inspection a new activities coordinator had been recruited, although they had not yet started work as not all the information from the required pre-employment checks had been received. Staff who we spoke to told us that they tried to compensate for the absence of a dedicated activities coordinator. Two staff who returned surveys to us, in response to the question “what could the home do better?”, commented on ‘activities’ as area which could improve. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 15 One staff member who we spoke to, when asked what the best thing about the home was, said a real connection with residents. I feel they can come and chat to us … [the staff are] a close-knit group who work well at making every day good for them [service users]”. There was also documentary evidence of an entertainer visiting the home a monthly basis. Birthdays and special festivals were also celebrated. Several people told us that the recent Halloween party had been a great success. There was evidence on files looked at that information about service users social history was sought and recorded. Examples were seen of books called my life story produced in conjunction with a life story project worker provided by a local charitable organisation. This detailed work was very well presented and served to reinforce an understanding of the unique and individual life experiences of the service user. We were told by the manager, staff, service users and relatives that there were no unreasonable restrictions on when service users could receive visitors. Staff told us they would try to accommodate family members who needed to stay over night if, for example, their relative was ill. Visitors who we asked, told us that they felt welcomed at the home. When asked what the best thing about the home was one visiting relative cited the friendliness of staff and another the welcoming, relaxed atmosphere. Another described the staff team as friendly and welcoming. All service users, visitors and staff who we asked, told us that people living in the home, were free to exercise choice throughout their time at Stoneleigh. This included when to get up, when to go to bed and whether they chose to spend time in the communal lounges or their own rooms. During this unannounced visit one meal was sampled. The food was tasty and pleasantly presented. Observation during lunch indicated that service users who need assistance with eating were being helped appropriately in a calm atmosphere. Everyone who we asked spoke positively about the provision of food in the home. One service user described the food as second to none and another confirmed that there was good choice of menu and you dont have to have what they say [on the menu]. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 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): 16 and 18. 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. Service users are protected from abuse or exploitation by the home’s policies and practices and are confident that any complaint they may have would be dealt with appropriately. EVIDENCE: The home has a written complaints procedure which has been found to be appropriate on previous occasions and was not looked at again on this visit. We were told by the manager that a copy of the complaints procedure is given to each service user. We looked at the record of complaints and none had been recorded since the previous key inspection. The manager confirmed that this record was up-to-date. All service users and visitors who we asked, were confident that any complaint they may have would be dealt with appropriately by the staff and management team. One relative said that if there were any problems staff sorted it out. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 17 Another visitor told us that they were more confident that the current management team would address issues than they had been some years ago. All staff who we asked, told us that they were confident that any complaint would be taken seriously and addressed. All staff who returned a survey to us said that they knew what to do if someone had concerns about the home. All service users who returned a survey to us said that they knew how to make a formal complaint and that they was someone they could talk to if they were not happy. The home had a copy of the local authority interagency safeguarding procedures. The manager had told us that most staff had received training in the protection of vulnerable adults. This was confirmed by staff who we spoke to and training records seen. Staff who we asked, demonstrated an understanding of the need to be vigilant in connection with the protection of adults and understood that need to whistleblow if necessary. Staff told us that they believed that the people living in the home were safe. All service users and visitors who we spoke to, also expressed the view that service users were protected from abuse or exploitation at Stoneleigh. At the time of this inspection visit the local authority safeguarding team were looking into one concern. We understood that staff and management at Stoneleigh were co-operating fully with this investigation. We have not been made aware of any complaints since the previous key inspection. Concerns identified at previous key inspection in connection with weaknesses in the recruitment procedures potentially putting service users at risk had been addressed. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 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): 19 and 26. 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. The home is appropriately maintained, decorated and cleaned to enable service users live in a pleasant, safe and hygienic environment. EVIDENCE: During this unannounced inspection we undertook a tour of the building. We looked at communal areas and a selection of service users’ bedrooms. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 19 We were told by the manager that there was a continual programme of repair and refurbishment. Some carpets, particularly on some stairs and some landings were looking a little worn in places. One windowsill was seen which required repair or replacing. The manager told us this had already been identified as necessary work. Apart from those matters identified above no remedial issues were identified during the site visit in connection with the fabric of the building. Since the last key inspection Stoneleigh has become entirely non-smoking. One service user told us that they though the lighting in the lounge could be improved. This observation was passed to the manager to look into. During the tour of the building no unpleasant smells were identified. All service users who returned a survey to us said the home was fresh and clean either always (2) or usually (2). All visitors and service users who we asked told us that the home was invariably clean, tidy and with no unpleasant smells. Two visitors cited the cleanliness of the home as among the best things about it. Service users who we asked told that they liked their room and it was clear from discussion and observation that people could personalise their own bedroom. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 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): 27, 28, 29 and 30. 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. The numbers and skills mix of staff on duty promotes the independence and well being of service users. EVIDENCE: And the time of this key inspection visit, Stoneleigh was accommodating 16 service users. Four carers were on duty and it was reported by the manager that currently this was the usual number of carers provided in the mornings. In addition to carers there were ancillary staff including a laundry assistant, domestics and kitchen staff. The manager said that staffing levels were adjusted depending on the number and needs of service users living in the home. We were given a copy of the staff Rota for the week commencing the 26th of October 2009 as evidence of these staffing levels. All staff who returned a survey to us said that there were usually enough staff on duty. Similarly staff who we spoke to told us they felt there were enough Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 21 staff on duty. Relatives also confirmed that they were usually enough staff on duty and one person told us that that they had been pleased to note that staff were in and out of the lounges all the time. Service users who returned a survey to us all said that staff were available either always (2) or usually (2). Service users who we asked told us that staff were available and responded in a timely manner if they needed assistance. The management team maintained a training matrix which enabled the easy identification of which training which individual staff members had received. A selection of information from this matrix was checked against certificates held in individual staff files and was found to be accurate. This information indicated that the significant majority of staff had received mandatory and core training, including moving and handling and protection of vulnerable adults. There was also documentary evidence that training opportunities, and where necessary, refresher courses, were made available for staff. In the Aqua provided to us by the manager in June 2009 we were told that 16 of the 26 staff members had completed level 2 or above in an appropriate NVQ (National Vocational Qualification). We were also told, by the manager, that the remaining 10 were enrolled on a course. The NVQ is a nationally recognised qualification intended to improve the knowledge and skills base for staff. All staff who returned a survey to us that they were given training which was relevant to their role, helped them understand and meet the individual needs of people and kept them up-to-date with new ways of working. All but one told us that training gave them enough knowledge about health care and medication . All staff who we asked, told us that a variety of training opportunities are available and that the management team were supportive and encouraged attendance. Staff also told us that they worked in a supportive team environment and were encouraged to seek advice or guidance if they needed to. We looked at files relating to the recruitment and vetting of some staff members since the previous key inspection. This was clearly much improved since the previous key inspection and provided documentary evidence that the legally required minimum checks had been undertaken. We were told that the procedure in connection with recruitment, within the company which owns Stoneleigh, had been changed. This new procedure enabled the manager in the home to be in more control of the recruitment process, than previously. All service users and visitors who we spoke to were positive about the staff team who were consistently described as pleasant friendly and welcoming. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 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): 31, 33, 35 and 38. 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. The manager is competent to run the home, use the quality audit systems and implement the health and safety procedures for the benefit of service users and staff. However, there has not been a long enough period of sustained good practice across all aspects of management to demonstrate consistency. EVIDENCE: Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 23 The registered manager had been found to be competent, appropriately qualified and experienced, through her successful registration application in January 2009. At the time of this key inspection visit the registered manager had just returned from several months absence due to maternity leave. Management arrangements which had been put in place to cover for her absence appear to have been predominantly satisfactory. The improvement plan submitted by the manager, following the previous key inspection, had been implemented. However it was not clear if the supervision and auditing of practice had been rigorously sustained. For example the poor record-keeping regarding prescribed creams was obvious even from a brief look at the records but did not appear to have been identified or addressed. The manager reported that quality assurance questionnaires had been distributed and returned from a variety of service users and relatives. She also told us that whilst issues raised through this process had been discussed, no written report was available. We looked at a small selection of records relating to money held and expenditure made on behalf of service users. These presented as being appropriately maintained to enable an effective audit trail and to protect the interests of service users. The manager had told us in the AQAA that equipment in the home had been serviced or tested as recommended. The lift contractor was on site during our visit and we looked at the records of the fire detection and alarm systems. There were good records of testing the fire alarm but there remained some confusion over the recording of the required checks to ensure that the means of escape, in the event of a fire, were clear from obstruction. The senior member of staff who had been undertaking the tests and maintaining the records reported that the means of escape were, in practice, regularly checked. During the tour of the building a small basket was seen in one communal bathroom which contained, amongst other things, several disposable razors which appeared to have been used. We were assured that there was no use of communal razors but it remained unclear why they had not been disposed of more appropriately and safely. Staff who we asked confirmed that personal protective equipment, such as disposable gloves and aprons, were always available and used. This is to minimise the risk of cross infection. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 X 2 X 3 X X 2 Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 25 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 OP9 Regulation 13 Requirement The responsible person must ensure that all records of the administration of medication, including prescribed topical creams, are accurately recorded. When necessary this must include evidence that any directions in connection with the timing of medication are adhered to. This is to ensure that the right person is getting the right medication in the right dose and at the right time, to gain maximum benefit from the prescription. Timescale for action 01/12/09 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 Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 26 1 OP9 The responsible person should ensure that the thermometer to record the temperature of the dedicated medicine fridge is easy to access and read. Records should be maintained to demonstrate ongoing monitoring. The responsible person should ensure that the results from any review of the quality of service analysed, if necessary acted upon, and a report is made available as to the outcome of the process. A copy of this report should be sent to the Care Quality Commission. The responsible person should ensure that staff practices in connection with all aspects of their work, including recording and ensuring potential hazards are removed from bathrooms are regularly checked and action taken to ensure that at least minimum standards are maintained. 2 OP33 3 OP38 Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 27 Care Quality Commission North West 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. 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. Stoneleigh House DS0000005521.V378140.R01.S.doc Version 5.3 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!