Inspection on 28/02/07 for Fieldhead Court Nursing Home

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fieldhead Court Nursing Home 02/03/09

Fieldhead Court Nursing Home 04/03/08

Fieldhead Court Nursing Home 27/07/06

Fieldhead Court Nursing Home 10/01/06

Fieldhead Court Nursing Home 10/11/04

Fieldhead Court Nursing Home 27/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Fieldhead Court Nursing Home Rectory Park Church Lane Thornhill Dewsbury West Yorkshire WF12 0JZ Lead Inspector Helen Battle Key Unannounced Inspection 28th February 2007 09:10 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 Fieldhead Court Nursing Home DS0000001082.V328297.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. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fieldhead Court Nursing Home Address Rectory Park Church Lane Thornhill Dewsbury West Yorkshire WF12 0JZ 01924 459000 01924 459000 fhcourt@rochehealthcare.com 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) Roche Healthcare Limited Mrs Kathryn Tanner Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2006 Brief Description of the Service: Fieldhead Court is a care home providing accommodation, personal and nursing care for up to forty older persons. It is owned by Roche Health Care Ltd, a private limited company with other registered care services in the district. The accommodation is a converted former rectory operating over two floors which are accessed by a passenger lift and stair lifts. There are thirty-two single rooms, of which 28 have en-suite facilities. There are four double rooms, 3 lounges and a small dining room. The accommodation is set within large grounds in a conservation area and has car-parking facilities. The provider informed the Commission for Social Care Inspection on 28 February 2007 that the fees range from £510 to £610 per week. There are additional charges for hairdressing, newspapers and magazines. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The inspector arrived at the home at 9.10 am and left at 4.10 pm. The purpose of this visit was to check progress following the last key inspection in July 2006. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: The staff at the home evidently work hard to meet the needs of the service users. Comments received from service users about the staff was positive. Positive feedback was also given by relatives who said that they are made to feel welcome, can visit in private, are consulted about their relative’s care and that they were all satisfied with the overall care. It was evident that the manager of the home has worked hard to build good relationships with the service users and relatives during the year and a half she has worked at Fieldhead Court. The meals provided at the home are of a good standard. Feedback from service users was positive regarding the meals provision. Activities are provided to meet the needs of the service users living at the home. Recruitment processes protect the service users living at the home. Monthly management reviews are carried out. The views of service users are sought regarding the service provided at the home. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 7 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 Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 not inspected. This home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to admission to the care home. EVIDENCE: The pre-admission information held for two service users were examined. These included a detailed assessment and a copy of a Community Care Assessment. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 ,9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are set out in the individual plan of care. Risk assessments are carried out and monitored regularly. The service users are not always protected by the home’s medication policy and procedure. Service users are treated with dignity, respect and privacy. EVIDENCE: The care plans of four service users were looked at. These were found to have been reviewed regularly, address the needs of the service users and included the involvement of service users and/or their family. It was evident that the staff know the needs of the service users and actually provide the care to meet those needs. This was observed on the day of the visit and confirmed by speaking to staff and service users. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 10 There was evidence in records that the health care needs of service users are met. Pressure relieving equipment is in place, and service users have access to GPs, specialist nurses and to chiropody, optical and dental services. The medication of four service users was checked. Not all the medication for all the service users could be reconciled with the records. There were a number of signature omissions and not all the medication received at the home had been signed in, therefore it was not possible to reconcile these medications with the records either. Medication prescribed on an “as required” basis could not be accounted for as records were not kept up to date. Generally, eye drops were dated when opened. These issues had already been identified by the manager and action is being taken to address this. Service users were seen to be treated with dignity and their privacy maintained on the day of the inspection. Service users spoken to said that they are usually treated well by the staff. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: The activities provision at the home is good. Christmas celebrations included a pantomime performed at the home by outside performers. Local nursery school children joined the service users to watch the pantomime. Carol concerts and sing-a-longs were also held. An activities co-ordinator is employed by the home for 20 hours each week. On the notice board near the entrance to the home, dates were displayed when the hairdresser visits and when the local Baptist church services are held in the home. The hairdresser was visiting the home and service users were seen to be enjoying having their hair done during this visit. Other activities include quizzes, bingo, animal therapy, word searches, entertainers, darts, skittles, local children singing and trips out. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 12 Service users are able to maintain contact with family and friends. Visitors were seen to come and go to the home during the day and one service user went out on the access bus to go to help at a church coffee morning during this visit. This is a regular weekly occurrence, much enjoyed by this service user. It was clear from speaking to service users that they are able to make choices about their everyday life, choosing what time they get up, go to bed and how and where they spend their day. The service users spoke about the meals at the home favourably. The main meal served at lunchtime on the day of this visit was fish or steak pie, served with green beans and roast potatoes, followed by currant sponge and custard. The inspector was invited to sample the meal and it was hot, tasty and nicely presented. Service users were offered drinks throughout the meal, such as juice, tea and sherry. Tables were set nicely and the meal appeared to be unhurried and relaxed. Service users who required assistance were helped in an appropriate manner by staff. Those service users who needed a soft diet were given a meal where individual portions of the meal had been liquidised. This is an improvement from the last visit in July 2006. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users, their relatives and friends are confident in raising any concerns and complaints. The service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in the entrance of the home. There have been no complaints to the home since the last key inspection in July 2006. Service users spoken with were aware of how to raise their concerns if they had any. The majority of staff working at the home have had adult protection training in the last twelve months. However, there were some gaps noted where there was no record of this particular training for a small number of staff. The manager gave assurances that this training would be delivered within a month of this visit. Staff spoken to on the day of the inspection had a good understanding of adult protection issues. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users live in a safe and overall well maintained environment that is generally clean and hygienic. EVIDENCE: Since the last visit a planned programme of refurbishment and decoration to service user rooms has been implemented. This is ongoing until July 2007. The decoration and new furniture is of a good standard. The recommendation in the last report regarding the replacement of the carpet in the “blue” lounge is being addressed and permission given for this to be replaced within the next three months. Plans to renew the extension of the home to improve facilities for the service users, ie reducing the number of double rooms, increasing the number of enFieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 15 suite rooms and putting in a shaft lift, are still being considered. However, the extension in place at present is now in need of redecorating and, should the plans to renew the extension not be commenced in the next six months, work to redecorate this area should be started. New commode chairs have been purchased since the last visit. The grounds of the home are extensive and beautifully maintained. There is an easily accessible patio area which is reported to be well used in the better weather. The driveway leading down to the home was very uneven and had a number of potholes in it at the last visit. The provider has addressed this and had the area levelled. However, due to recent poor weather and flooding, the driveway is again becoming uneven. This needs to be monitored by the provider and action taken if necessary. The external window frames need redecorating. The paint is cracked and peeling. The home was clean and free from unpleasant odours. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers. Staff receive induction and ongoing training. The recruitment process ensures the service users are sufficiently protected by the home’s recruitment policy. EVIDENCE: Rotas indicate that staffing levels are currently: AM 1 nurse and 7 care assistants PM 1 nurse and 6 care assistants Nights 1 nurse and 3 care assistants A requirement was made in the last inspection report regarding staffing levels. Rotas seen during this visit indicate that staffing levels have improved, however they are still not at the level recommended when using the residential staffing formula. The dependency levels of the service users and the layout of the building indicate the need for a higher level of staff. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 17 Further staff should be deployed to meet the needs of the service users, i.e. staffing levels should be: AM 1 nurse and 8 care assistants PM 1 nurse and 7 care assistants Nights 1 nurse and 3 care assistants Staff observed on the day of this visit appeared to be competent in meeting the needs of the service users. Evidence of induction training was seen and records of training were provided. Although the majority of staff have received training in areas including health and safety, movement and handling, adult protection and fire safety, there are a small number of staff who have not had recent updates. This must be addressed. The recruitment records for four members of staff were examined. All had the required checks in place. This is a marked improvement from the last visit. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a manager who is fit to be in charge. Generally, the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. The health and welfare of service users and staff is promoted and protected. EVIDENCE: The registered manager has been manager at the home for the last year and a half. Feedback from staff and service users on the day of this visit was positive about her role and how approachable she is. It was evident, from observation Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 19 on the day of the visit, that the manager has built good relationships with the service users and their families. The manager has carried out some quality assurance monitoring and has received feedback from relatives and service users. These results are being collated and will be published in a letter which is been sent out to all relatives and service users. This is a repeat of the process carried out last year. Monthly management visits are now being carried out. This is a positive move forward and the service is evidently feeling the benefit of these visits and the support they provide. The personal monies for two service users were checked as part of this inspection. Both were found to tally with the records held. The general health and safety of service users is promoted at the home. There were no specific issues noted during this visit. Tests of the fire alarm system and the emergency lighting system are recorded as being carried out weekly. This is an improvement from the last visit. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 20 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 1 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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) Timescale for action The registered person shall make 31/03/07 arrangements for the recording, handling, safe keeping, safe administration and disposal of medications into the care home. Previous timescales of 10/01/06 and 11/08/06 not met. All staff must have training appropriate to the work they are to perform. Gaps in training must be addressed. Requirement 2. OP30 18(1)(C) 01/04/07 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. 2. Refer to Standard OP19 OP19 Good Practice Recommendations The carpet in the blue lounge should be replaced as planned. Should the plans for work on the new extension not be commenced by 30.06.07 then the existing extension DS0000001082.V328297.R01.S.doc Version 5.2 Page 22 Fieldhead Court Nursing Home 3. 4. OP19 OP27 should be refurbished. The condition of the driveway should be monitored and action taken when needed. Staff must be deployed in such numbers as appropriate for the health and welfare of service users. Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Fieldhead Court Nursing Home DS0000001082.V328297.R01.S.doc Version 5.2 Page 24 - 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!