Inspection on 01/05/09 for Hadley Lawns

This is the latest available inspection report for this service, carried out on 1st May 2009.

CQC found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hadley Lawns 12/07/06

Hadley Lawns 07/02/06

Hadley Lawns 16/05/05

Hadley Lawns 01/11/04

Hadley Lawns 05/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hadley Lawns Kitts End Road Barnet Hertfordshire EN5 4QE Lead Inspector Daniel Lim Unannounced Inspection 10:00 1st May 2009 DS0000010449.V375240.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hadley Lawns DS0000010449.V375240.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 Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadley Lawns Address Kitts End Road Barnet Hertfordshire EN5 4QE 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) 020 8449 0324 020 8449 9097 irelandm@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Margaret Rose Ireland Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 44 8th May 2007 Date of last inspection Brief Description of the Service: Hadley Lawns Care Home is owned by BUPA and is registered to care for a maximum of forty-four older people. The home provides personal care and nursing care. The registered manager of the home is Mrs Maggie Ireland. The home aims to maintain the high standards of care and comfort in a way that meets personal needs. The home is a two storey detached house. There is a lift between the ground and first floors. There are forty-four bedrooms located on the ground and first floors. All bedrooms are single and have en-suite facilities. The ground floor has a reception area, managers office, a staff room and kitchen. There is also a large dining room, two communal lounges and residents’ bedrooms. On the first floor there is another large communal lounge / diner, kitchenette and residents bedrooms. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The gardens are attractive and seating is provided. The home is about half a mile from shops, restaurants and community facilities located in High Barnet. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 5 Details of the fees charged by the home may be obtained from the manager. The provider must make information about the service available (including reports) to service users and other stakeholders. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience Excellent quality outcomes. This inspection was carried out on 1st May 2009 and took a total of eight and a half hours to complete. A second visit was made on the 5th May 2009 to view documents, interview staff and residents. We were assisted by the registered manager, Mrs Margaret Ireland. The regional manager (Mr Andrew Jeavons) was present for part of the inspection during the second visit. Five residents, a friend of a resident and three relatives were interviewed. The feedback received from them was positive and indicated that they were satisfied with the care provided. Completed questionnaires were received from one resident, a representative of a resident, three staff and two professionals. These were all positive and indicated that residents were well cared for. Statutory records were examined. These included five residents’ case records, the maintenance records, accident and incident records, complaints’ records and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen, garden and communal areas were inspected. Six staff were interviewed regarding the care of residents and other areas associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB disclosures, references, supervision and training records were examined. In addition, the minutes of residents and relatives meetings were examined. These indicated that residents had been consulted and informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form (AQAA) was received by us. Information provided in the assessment was used for this inspection. What the service does well: Residents were able to confirm that they had been treated with respect and dignity by staff and their care needs had been attended to. We note that effort had been made to improve the care provided. The home had enrolled for the Gold Star award in Palliative Care and it is now in it’s final phase (Phase 5) for Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 7 achieving the award. In addition, the manager had devised an Empathy training course for her staff. This is to assist staff in listening to residents and better understand them and any problems they may have. There is a comprehensive staff training chart on display in the office detailing training provided and planned. The home has a part time training co-ordinator who constantly checks and updates the training programme for staff. The home is furnished to a high standard. We note that bedrooms inspected have en-suite facilities and appeared cosy and comfortable. We note that airconditioning had been provided to some areas of the home to improve the environment for residents. What has improved since the last inspection? 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. Hadley Lawns DS0000010449.V375240.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 Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Stds : 3, 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. Admissions are not made to the home until a full needs assessment has been undertaken by the manager or a sufficiently skilled member of staff. This ensures that the home is able to meet the needs of residents. EVIDENCE: The pre-admission assessments which were examined were noted to be appropriate and comprehensive. These assessments included details of the personal, mental, cultural and spiritual needs of residents. Risk assessments had also been prepared for residents admitted to the home. The home’s AQAA made the following statement. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 10 “We have implemented QUEST - BUPA Care Homes new comprehensive client assessment and personal planning system. We have a named Personal Best Champion to lead and guide staff to aim for the very best in all aspects of their work.” Residents in the home were noted to be clean and appropriately dressed. They and their relatives who were interviewed by us indicated that residents were well cared for and their care needs had been attended to. This was reiterated in completed questionnaires received. Comments made by residents interviewed included, “ Staff are helpful and respectful” “ They will do it for you if they can” and “ Very nice home”. The manager indicated that effort is being made to foster a homely and friendly atmosphere within the home, with the aim of assisting residents adjust to their new environment. The manager stated that the home does not provide intermediate care. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Stds : 7, 8, 9, 10 People using the service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal and healthcare support specially tailored to their individual needs. Staff respect people’s preferences and provide care that is sensitive and responsive. Where areas for improvement emerge, the service recognizes and manages them well. Staff are competent and alert to the needs of residents. Care documentation is up to date and well written, although some improvement is needed. Residents are protected by the home’s satisfactory arrangements for the administration of medication. EVIDENCE: Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 12 Comments made by residents and their relatives in interviews indicated that the personal and healthcare needs of residents are being attended to. This was also reiterated in completed questionnaires received. Residents interviewed stated that they were well cared for and they had access to healthcare when needed. The manager informed us that staff are diligent in ensuring that the needs of residents are met. She reassured us that nurses in the home routinely check to ensure that the required care needed by residents and allocated tasks are carried out. She informed us of an example of good practice. We were provided documented evidence that the home had enrolled for the Gold Star award in Palliative Care. She stated that this was aimed at improving the quality of care for residents and reduce hospital admissions. The home is now in the final phase (Phase 5) for achieving the award. She informed us that effort had been made to clearly identify and record the preferences of residents and ensure that night care plans are in place. The AQAA stated that “All residents have comprehensive personal care plans individual to their identified needs. We have a comprehensive suite of Policies and Procedures and the Royal Marsden Manual of Clinical Procedures. There are company specialists both regionally and nationally who can be consulted for advice and support at any time. Self care is encouraged.” Five case records were examined. These contained care plans, daily notes and observation charts. There was evidence that residents had access to healthcare professionals such as the chiropodist, dentist and their GP. The manager informed us that a physiotherapist visits the home regularly to attend to the needs of residents. Individual care plans had been prepared for residents following their assessment. A sample of five care plans which was examined were on the whole well prepared and regular monthly care reviews had been carried out. The plans prepared had been signed by residents or their representatives. These were up to date and had been reviewed monthly. We however, noted that cultural and spiritual care plans were not prepared for residents. The manager explained that residents concerned had not expressed any needs in these areas. Our view is that cultural and spiritual plans are needed for residents unless residents have not wanted them. If this is the case, this must be clearly stated in the case records. A recommendation is therefore made in this report for cultural and spiritual care plans to be prepared for residents and where this is not needed, it should be clearly stated. Nutritional monitoring and weight monitoring charts were evident. Appropriate risks assessments had been prepared for residents. These were of a good standard. The care plan of a resident who was at risk of pressure sores was examined. This contained an appropriate pressure area care plan. We note that one resident who had a pressure sore had recovered and no longer has a Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 13 pressure sore. We were informed by the Head of Care that another resident with a pressure sore had also improved significantly. The pressure area turn chart of one of the residents was examined. We note that staff had been diligent in carrying out their duties in ensuring that position changes are done and the care plans are followed. The head of care was knowledgeable regarding the care of pressure areas. The home has a medication policy and procedure. However, the procedure we examined was dated August 2005. This was brought to the attention of the manager who agreed to obtain an updated policy and procedure. The two treatment rooms were air-conditioned. The temperature records of these rooms and the fridge where medication was stored had been recorded daily. They were satisfactory. The medication charts of four residents were examined. These indicated that medication had been administered as prescribed and appropriately signed by staff. The controlled drugs record of a resident was examined. These were accurate. The arrangements for ordering of medication was satisfactory. The home has a licensed contractor for the disposal of medication. Controlled drugs were denatured and kept in a special container prior to disposal. Other medication which were not controlled drugs were disposed of in a large container. This container which contained tablets was stored horizontally. We note that this container was large and was quite full. Staff had some difficulty accessing this container as it was bulky and there is risk of spillage. This was brought to the attention of the manager who agreed to review the arrangements with the contractors and staff concerned. We were aware that a complaint had previously been made regarding the care of a resident who had experienced falls. This had been fully investigated and resolved. Although staff had been vigilant in their observations, the manager had nevertheless provided additional guidance to staff on the management of falls experienced by residents. The manager informed us that to further improve care, she had devised an Empathy training course for her staff. This training is unique in the organisation. The aim was to assist staff in listening to residents and better understand them and any problems they may have, thus leading to a more responsive and personalised care. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Stds : 12, 13, 14, 15 People using the service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The daily life, meal arrangements and routines of residents are well organised. The views of residents and their relatives are being sought when planning the activities and routine. People using the service are given the opportunity to take part in activities that are imaginative, appropriate and varied. They also have opportunity to maintain important family relationships. Residents are offered wholesome and varied meals which meet their needs and preferences. EVIDENCE: The home’s AQAA made the following statement ‘We have a structured activities programme tailored to the individual needs and preferences of our residents. The home has an open visiting policy taking account of residents wishes. We encourage the personalisation of residents’ individual space with their personal belongings. A full and varied menu is Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 15 available in the home. The BUPA Menu Master helps us to ensure the menu meets the nutritional needs of the residents. The menu reflects the cultural and religious preferences of residents. We involve the residents in menu requests. Ensure that the monthly menu is varied and follows BUPA Menu Master guidelines. Ensure all residents are aware of ‘Night Bite’. We have started the BUPA Night Bite system to ensure that food is available 24 hours a day.” The home has an activities organiser. She was busy organising a flower arrangement session when we visited. The manager stated that residents are encouraged to maximise their independence and there is a range of daily activities that residents could participate in. The programme of weekly activities included local walks, exercise sessions, music, exercise, entertainment sessions and art and crafts. Coach trips were organised to see the Christmas lights and a local pantomime. Visits were also made to the local garden centre. In addition, the manager stated that one to one sessions were also available for residents. There was documented evidence that residents had been consulted regarding activities they would like to engage in. Details of residents personal preferences were also documented. A record of acitvities that residents had engaged in was documented in the case records of residents. Residents and three relatives interviewed were able to confirm that the home has a range of activities which residents can participate in if they wanted to. We were also informed by the manager religious and cultural events and holy days are organised by the activities organiser and celebrated in the home. These included Christmas, Easter, Ramadan, Diwali, Remembrance Day and Hanukkah. In addition, there are frequent food tasting sessions for residents to experience foods from other cultures and countries. Residents are able to keep in touch with their friends and relatives. This was evident during the inspection and we were able to interview a friend and three relatives of residents. It was also confirmed in case records examined and in entries in the visitors’ book. The kitchen was clean and well equipped. A record of fridge and freezer temperatures had been kept. These were satisfactory. The chef who was interviewed was knowledgeable regarding his responsibilities and the special dietary needs of residents. The menu examined was varied, balanced and there was a choice of main dish. The dining room was attractive and furnished to a high standard. Residents interviewed stated that they were happy with the meals provided. We were present during the lunch period. We note that the meals were presented in an attractive manner. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Stds : 16, 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. The arrangements for responding to complaints and for adult protection are satisfactory. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. The required policies and procedures for safeguarding residents are in place and give the required guidance to staff. Regular training in safeguarding is provided for staff. EVIDENCE: The homes AQAA made the following comments. “We have a clearly defined company complaints policy with agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA Care Homes have robust policies for dealing with allegations of abuse or neglect. Staff can not only raise concern within the home they have access to senior staff outside the home. Each and every complaint is responded to promptly. Compliments are Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 17 recorded and displayed in the reception area. BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts. During this year Bupa has had a working party examining the complaints process and guidelines and procedures are being produced to further improve this area. Hadley Lawns has developed Empathy Training for staff which with their Personal Best helps tocreate an even greater empathetic workforce.”. Residents and their relatives who were interviewed by us indicated that they were well treated and satisfied with the care provided to residents. The home has an adult protection procedure. It included examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CQC. The local authority guidelines were also available. The manager and her staff who were interviewed were aware of the homes policy and procedures for the protection of vulnerable adults. There was evidence that staff had been provided with the required training. The home has a record of complaints received. There was documented evidence that they had been promptly responded to within the required timescale of 28 days. When asked, residents said they know who to complaint to if they wanted to make a complaint. This was also reiterated in completed questionnaires received from a resident and a representative of a resident. During the first day of inspection a resident stated that staff did not always respond promptly when she activated the call bell. This resident was happy for us to relay her concern to the manager. During the second visit, the manager was able to provide us with a printout of the call bell response times. This indicated that calls made by the resident had been promptly responded to. We had also activated the call bell on the first day in this room and note that staff responded promptly. On the second day of inspection, a resident told us that she had made two complaints to the manager. She said the manager had responded satisfactorily to her complaints. No other complaints were received from any other person interviewed by us. The home has a record of compliments received. Comments made included the following “The staff here are very good and have been very kind to me.” “My family and I wanted to express our sincere thanks and gratitude to you and all your colleague who kindly looked after my mother.” “It has been a privilege to get to know you all…thank you for your care and dedication.” “Thank you for your kindness.” Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 18 “Your staff are a great credit to you.” Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 19 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): Stds : 19, 20, 22, 23, 24, 25, 26 People using the service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean, tidy and furnished to a high standard. The manager has ensured that the physical environment of the home provides for the individual requirements of people who live there. The necessary equipment and adaptations for supporting residents are available. Residents are allowed to personalise their bedrooms. Overall, the home provides a pleasant, comfortable and attractive environment to live in. EVIDENCE: Residents interviewed by the inspector indicated that they were happy with the accommodation provided and their bedrooms had been kept clean. The Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 20 reception area had been re-organised and new and comfortable chairs had been provided. Leaflets and the home’s service user guides were on display here. This area appeared welcoming and cheerful. The home employs a full time maintenance person on site. He was knowledgeable regarding his responsibilities and the maintenance of the home. The manager informed us that the roof had been repaired and five new boilers had been installed. The home’s AQAA made the following statements. “We use a specialist micro-fibre cleaning system that combined with effective cleaning regimes keeps the home clean and odour free. Our comprehensive policies and procedures include control of infection and handling clinical waste. Services and facilities comply with the Water Supply (Water Fittings) regulations. The home is supported in maintaining the environment by a central team of experts within BUPA Care Homes. We have a specialist property and estates department as well as a hotel services department. Hadley Lawns is well equiped, clean and furnished to a high standard providing a pleasant environment in which to live. Attractive garden, colourful with ample seating. A centre feature of aromatic plants and herbs creates a sensory area.” We note that bedrooms inspected have en-suite facilities and appeared cosy and comfortable. The toilets and hand basins were clean. Bedrooms inspected by us had been personalised by residents with their own pictures and ornaments. We note that air-conditioning had been provided on the first floor and in the laundry and treatment room. Various specialist equipment for the care of residents was available. These included hoists, assisted baths, toilet handrails, wheelchairs, carendo chair (shower chair for heavier residents) and a call bell system. A printout of the response times for call bells is available. The gardens were attractive, colourful and seating had been provided. There is a fountain and a small sensory garden nearby. There is a path through the garden and around the house. This path was clean. There is a new porch seat for residents to sit on. The laundry was inspected and we note that laundry staff reported that care staff followed procedures for ensuring that soiled linen and clothes are put into the appropriate bags. Soiled laundry items are subject to a special high temperature wash. This ensures effective infection control and protects the health of residents. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 21 The required safety inspection had been carried out on the gas, electrical installations and portable appliances and documented evidence was kept in the home’s maintenance folder. An additional second front door bell is in place. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 22 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): Stds : 27, 28, 29, 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a good recruitment procedure that is followed in practice. The manager recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are satisfied with the staffing arrangements. EVIDENCE: The home’s AQAA made the following statements. “There are comprehensive Human Resource policies to aid effective recruitment and staff management. We maintain the correct numbers of staff agreed with the inspectorate and taking account of the individual needs of the residents. Following the last CSCI inspection a staffing review was undertaken and a flexible regime implemented. When occupancy is above target additional staff are recruited to work with the residents. We perform appropriate CRB, POVA and NMC PIN checks for staff. There is a training matrix specific to the home that identifies the training requirements of the staff. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 23 The staff rota was examined. This indicated that in addition to the manager and her deputy (head of care) there was a minimum of 8 staff on duty during the morning shifts (6 carers & 2 nurses), 6 staff on the afternoon and early evening shifts (4 carers & 2 nurses) and 5 staff on the night shifts (4 carers & 1 nurse). Staff interviewed were of the view that the levels were adequate and they were able to attend to the needs of residents. This was also reiterated in 3 completed staff questionnaires received by us. The manager is aware of the need to keep staffing numbers under review to ensure that the home can continue to meet the changing needs of the people living there. Five staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. There was documented evidence in staff records to indicate that staff had been provided with essential training relevant to their area of work. The manager stated that their training arrangements are an example of good practice. There is a comprehensive staff training chart on display in the office detailing training provided and planned. The home has a part time training co-ordinator who constantly checks and updates the training programme for staff. In addition, the manager informed us that she had devised an Empathy training course for her staff. This is to assist staff in listening to residents and better understand them and any problems they may have. The records of four new staff were examined. These indicated that the required recruitment standards and procedures such as obtaining satisfactory CRB disclosures and references had been followed. There was documented evidence of regular formal staff supervision. This was also confirmed by staff interviewed. The supervision notes indicated that staff had opportunity to discuss any work related problems, issues related to the care of residents and their training. The issue of equalities and diversity was discussed with the manager and her staff. Staff demonstrated an understanding of the need to treat all residents sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. They were aware that they must not discriminate against residents and they indicated that this was stressed to them during their induction. The four residents who were interviewed indicated that they had been treated with respect and dignity by staff. This was also confirmed by the two relatives interviewed. The home’s AQAA made the following statement in the area of Equality and Diversity. “We consider all denominations and ensure that each resident who wishes is Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 24 able to practice his/her faith. Integral throughout all we do we consider each person as an individual and endeavour to be fair and flexible to their needs. Dietary requirements relating to religious belief is accommodated. For example when we had a resident of Jewish faith we accommodated their wishes by arranging for Kosher meals to be delivered to the home.” Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 25 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): Stds: 31, 33, 35, 38 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be assured that the home is well run and the manager has skills and ability to deliver a good quality of care and meet it’s stated aims and objectives. Records are well maintained. There is an effective system for maintaining health and safety. Residents and their representatives are consulted regarding the care provided and the management of the home. EVIDENCE: Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 26 The registered manager was found to be knowledgeable regarding her role and responsibilities. She is a qualified nurse with extensive experience in the care field and she has obtained management qualifications. She is supported by a Head of Care and two clerical staff. The home’s AQAA made the following statement. “There are regular Health & Safety meetings with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from these meetings go to the Regional Manager. There are regional and national experts available within the company for advice and guidance if required. There are dedicated Health & Safety staff within the Quality and Compliance directorate. BUPA Care Homes has a comprehensive suite of Policy and Procedure manuals that are regulalrly reviewed by experts and updated when required. BUPA Care Homes has an annual customer satisfaction survey. Staff receive regular supervision sessions. BUPA Care Homes has achieved Investors In People (IIP) acreditation.” Feedback received from residents and their representatives indicated that the manager had been successful in fostering a caring and welcoming environment where residents are cared for with respect and dignity regardless of their background, race, religion, disability or sexual orientation. There was evidence that residents are consulted regarding the management of the home. Residents’ and relatives’ meetings had been held. The minutes of the latest residents’ meeting were examined. It indicated that residents and relatives were informed of progress in the home and informed about staffing arrangements. The home has a development plan. A consumer survey had been carried out recently and there was evidence that the respondents were satisfied with the management of the home. We note that the level of satisfaction had been higher at this recent survey than previously. An action plan had been prepared in response to suggestions and deficiencies noted. Weekly fire alarm checks and regular fire drills had been documented. The home has an up to date fire risk assessment. We were informed by the manager that a detailed fire evacuation plan is also in the process of being prepared by the company’s Health & Safety officer. Staff had been provided with training in Fire Safety and Health and Safety. The manager informed us that new door closures had been fitted following their fire risk assessment. The accident records were appropriately filled in and we had been informed of significant accidents and incidents. The maintenance person stated that weekly safety checks had been carried out and these were documented. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 27 The home has a current certificate of insurance. No financial records of residents were examined. The manager informed us that the home does not keep any money on behalf of any resident. Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 28 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 bCHOICE 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 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 3 X 3 4 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 29 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(2) Requirement The medication policy and procedure must be updated. This is to ensure that staff are provided with up to date guidance on the administration of medication. Timescale for action 13/07/09 Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 30 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 OP9 Good Practice Recommendations The arrangements for the disposal of medication in the large container must be reviewed with the contractors and staff concerned. This is to ensure that medication is disposed of safely. Cultural and spiritual care plans should be prepared for residents and where this is not needed, it should be clearly stated in the case records. This is to ensure that the holistic needs of residents are met. 2 OP7 Hadley Lawns DS0000010449.V375240.R01.S.doc Version 5.2 Page 31 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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