Inspection on 04/08/06 for Haddon Court Nursing Home

This inspection was carried out on 4th August 2006.

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 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

Haddon Court Nursing Home 03/08/07

Haddon Court Nursing Home 14/11/05

Haddon Court Nursing Home 26/05/05

Haddon Court Nursing Home 27/07/04

Haddon Court Nursing Home 25/05/04

Haddon Court Nursing Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Haddon Court Nursing Home High Street Beighton Sheffield South Yorkshire S20 1HE Lead Inspector Mr Rob Curr Key Unannounced Inspection 4th August 2006 08:00 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 Haddon Court Nursing Home DS0000021781.V298125.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. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon Court Nursing Home Address High Street Beighton Sheffield South Yorkshire S20 1HE 0114 251 1318 0114 251 1354 none 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) Amocura Limited Mrs Janet Sharp Care Home 83 Category(ies) of Dementia - over 65 years of age (62), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (21) Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 62 dementia elderly (DE/E) beds 10 can be used for mental disorder elderly (MD/E). One service user, named on the variation to registration application form dated 21/04/03 and who is under the age of 65, may reside at the home. 14th November 2005 Date of last inspection Brief Description of the Service: Haddon Court is situated in Beighton Village, approximately five miles from the city centre. The home is within easy access of the local community, which has a selection of shops and churches. Haddon Court is a purpose built care home. It provides both nursing and personal care for older people who are mentally infirm or those who suffer from a mental illness. Current fees range from £400 - £488. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Two inspectors undertook the site visit, from 8.30 am until 5.00 pm. The second inspector was Mr Steve Baker, a Pharmacy Inspector with the CSCI who was currently undergoing the induction process. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. A number of care staff and nurses were spoken to about their skills and experiences of working at the home. Discussions took place with the registered manager and a director of the company. A number of residents were interviewed along with four relatives. The inspector would like to thank the manager and her staff team for their support and commitment to the inspection process. What the service does well: What has improved since the last inspection? The manager has continued to encourage relatives to attend support meetings. Staff had continued to receive training in food hygiene and nutritional and dietary needs. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 6 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. Haddon Court Nursing Home DS0000021781.V298125.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 Haddon Court Nursing Home DS0000021781.V298125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Residents’ needs were assessed prior to admission. Residents and their relatives were fully involved in the assessment and admission process, so this ensured that the home was able to meet their needs. The manager did not offer places to any individual whose needs they could not meet. The staff-training plan was on target. EVIDENCE: Copies of full need assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. Two relatives said that they had been invited to view the home and attend a variety of meetings prior to their relative moving into the home. Staff training records indicated that they had undertaken relevant training required to assist them in caring for the people that reside at Haddon Court. Haddon Court Nursing Home DS0000021781.V298125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Each resident had a plan of care, to inform staff of the actions required to meet assessed need. Records indicated that residents’ health care was monitored, to maintain health. The recording and administration of medication was well managed, to promote residents safety, although there some minor issues around the format of the medication sheets. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 10 EVIDENCE: A number of care plans were examined. Some sections of the care plans seen were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication. There were a number of residents being care for in their bedrooms. On meeting these residents it was observed that they all had the appropriate support in terms of general health care and personal hygiene. The plans contained records of health assessments, such as moving and handling and skin integrity. Nutritional assessments were undertaken. health care needs were met. Residents and visitors said that Qualified staff administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely. Care plans contained information on contacts with health care professionals, such as general practitioners and specialist nurses. Medication was stored securely. Medication administration records were fully completed and up to date. There were some minor issues around the medication recording system. • • • Medicines were prescribed ‘as required’ without guidance e.g. for mild pain or severe pain. Absence of information in the ‘allergies known’ boxes. Not all MAR sheets recorded resident’s date of birth. The Pharmacy Inspector noted that these issues were not the fault of the management, but could be resolved through he GP and the local pharmacist. The manager does not operate a ‘homely medicines’ policy. There is a possibility of medicines being prescribed unnecessarily resulting in waste. The BNF (medicines guide) was five years old and should be replaced with a current edition. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Residents preferred form of address was respected. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 11 Staff were seen to treat service users respectfully. Staff promptly responded to residents that became anxious in a kindly, reassuring and patient manner. One relative said that staff were ‘always patient and caring’. A policy and procedure were in place regarding dying and death. Relatives spoken with confirmed that they were kept informed of their loved ones health. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area was good, but further improvements in the activities programme are needed. This judgement has been made using available evidence, including a visit to the home. Activities were provided to residents by a member of staff, to improve choice and quality of life. The routines at the home were flexible and service users were able to choose how to spend their time, in line with health and safety and assessed risk, to maintain and improve the quality of life. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends were supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. The catering team are very committed to providing a choice of menu, supporting any resident that has individual likes and dislikes. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 13 EVIDENCE: A member of staff provided activities. On the day of the inspection the person that offered activities was on holiday so any activities were limited due to staff time and availability. In addition, staff reported that the majority of residents were unable, or chose not to, participate in planned group activities. Residents were seen to walk freely around the home. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns at all about the care of my relative, I am very happy with the care provided’. Staff supported residents choices, and were overheard to offer individuals choice of breakfast. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘lovely’. Staff sat with the residents that required assistance with eating, and this support was given patiently and respectfully. The cook and her team were clearly aware of individual residents special dietary requirements. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in place. Staff were fully aware of these procedures, to ensure residents safety was promoted. EVIDENCE: The complaints procedure was on display in a communal area of the home. This procedure informed residents and their representatives of the providers approach to complaints. A record of complaints was kept. One complaint had been received sine the last inspection – this had been handled well and the outcome was recorded. The staff spoken with were clear about the procedures to undertake in regard to adult protection and about the homes complaints procedure. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Controls of infection procedures were in place, to promote resident’s health and safety. EVIDENCE: A tour of the building identified that some areas of the home were in need of decoration and furniture replacement. The manager had highlighted this to the inspectors and produced a list of furniture that was to be replaced. Some homely touches were provided to create a comfortable environment for the residents. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 16 A handy person was employed to help maintain the environment. A rolling programme of redecoration and replacement was in place but this needed to be monitored closely. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Sufficient staff were provided to meet the needs of the residents. The recruitment procedures operated in line with equal opportunities. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 in care was on target. The manager could identify the training needs of the staff group. EVIDENCE: There were enough staff on duty during the day and night to care for peoples needs. One resident and a relative said that the staff were ‘very good’ and ‘very helpful’. All staff files checked had an appropriate Criminal Records Bureau (CRB) disclosure. 32 of care staff had completed the National Vocation Qualification (NVQ level 2 & 3) in direct care. A further group of staff are currently on the course and some have registered to commence the training. Haddon Court Nursing Home DS0000021781.V298125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. There was a positive style of management in the home. This clearly benefits the residents and their relatives and representatives. There was a quality assurance system in place, which gave residents and visitors an opportunity to express their views and suggest ways in which the service may be improved. Staff supervision systems were in place to ensure best practice was maintained. All records were securely stored. Health and safety checks were in place to ensure residents were safe. All staff had undertaken fire training. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 19 EVIDENCE: Staff said that the manager was approachable, supportive. One adaptation nurse was very grateful for the education and support she had received from the management. The manager had an annual plan that identified and prioritised areas for improvement, to enhance the service provided. The ‘quality assurance questionnaire report’ was able to inform relatives and other interested parties, the current views of the service. Care staff and nurses said that the frequency of their supervision sessions had lessened, although they acknowledged that this could be due to staff sickness and annual leave. Fire records were maintained of fire alarm tests. The fire drill records indicated that staff (including night staff) had undertaken a fire drill practice within the last year. The inspector noted that there was a high number of accidents reported. All these reports were clear and accurate. Since the last inspection the manager has begun to monitor the number and type of falls taking place. It was suggested by the inspector that the manager begins to analyse this information and develop ways in which to minimise the incidents. Haddon Court Nursing Home DS0000021781.V298125.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 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 3 Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 21 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 2 3 4 5 Standard OP9 OP9 OP19 OP24 OP25 OP24 OP25 Regulation 13 13 23 23 23 Timescale for action The ‘homely remedies’ policy and 25/09/06 practice should be put into practice where appropriate. A current edition of the BNF 25/09/06 should be purchased The general maintenance 25/09/06 programme should be closely monitored. The identified damaged and 30/10/06 worn furniture must be replaced. A detailed programme of 25/09/06 furniture replacement must be forwarded to the local office of the CSCI. The current programme of NVQ 04/08/06 training must continue. The supervision programme 04/08/06 must be adhered to as closely as possible. Requirement 6 7 OP30 OP36 13 18 Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 22 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 3 4 5 Refer to Standard OP9 OP9 OP9 OP12 OP38 Good Practice Recommendations Pain relief medicines given ‘as required’ should have further guidance in relation to pain severity. The MAR sheet section for ‘any known allergies’ should be completed. MAR sheets should contain resident’s date of birth. Consideration should be given to the activities being offered by a full time worker or equivalent. The management should develop a strategy to lessen the incidents of falls and accidents. Haddon Court Nursing Home DS0000021781.V298125.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 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 Haddon Court Nursing Home DS0000021781.V298125.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. 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