Inspection on 21/02/06 for Hadleigh Court

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hadleigh Court 01/08/07

Hadleigh Court 09/03/07

Hadleigh Court 21/06/05

Hadleigh Court 16/03/05

Hadleigh Court 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Hadleigh Court Hadleigh Court Stanley Road Torquay Devon TQ1 3JZ Lead Inspector Sharon Goldsworthy Unannounced Inspection 21st February 2006 09:50 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 Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hadleigh Court Address Hadleigh Court Stanley Road Torquay Devon TQ1 3JZ 01803 327694 01803 327694 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) Babbacombe Care Limited Mrs Barbara Denise Wright Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (31), Physical disability over 65 years of age (31) Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Hadleigh Court is registered to provide accommodation with personal care for up to 31 people aged 65 or over, who may have a level of dementia, other mental disorder or physical disability. The home is on two floors and has a shaft passenger lift connecting the ground and first floors. Private accommodation is provided in 25 single bedrooms, 21 of which have en suite facilities, and 3 double bedrooms all of which have en suite facilities. There are also communal bathrooms and toilets throughout the home. In terms of communal space there is a large lounge and adjoining sun lounge, and a large dining area. There is an attractive level garden with ramped access, and a car parking area. The building itself is a large detached property located in a level residential area of Torquay, almost adjacent to a local park and quite near to local shops and other amenities in St Marychurch and Babbacombe. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a week day for the duration of 6 hours. Time was spent with the manager reviewing previous requirements and recommendations and current working practices and issues within the home. A tour of the premises was conducted. Observations were made of some documentation and of care practice in the main communal rooms, including activities. What the service does well: What has improved since the last inspection? Staff training has continued since the last inspection as has staff supervisions, appraisals and individual observed care practice. Care plans have been reviewed and now record a good level of detail in relation to individual’s needs. Some refurbishment of the building (including some bedrooms) has continued. Staff recruitment practices – in terms of obtaining Protection of Vulnerable Adults List checks are now completed for all new staff. The home’s quality assurance programme continues. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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 Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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): None of these standards were considered in depth at this inspection visit. EVIDENCE: Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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 Residents’ health, personal and social care needs are clearly set out in care plans. EVIDENCE: A sample of care plans and daily records were inspected – in particular for recently admitted residents and residents who have a high level of need currently. The home has fully reviewed and amended all care plans and daily records. All records are detailed, reviewed, risk assessments are complete and daily records are complete and reflect the current level of needs and level of monitoring. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 10 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 Residents general lifestyle and social activities match their expectations and preferences. Residents are enabled to maintain contact with friends and relatives and the local community and are able to exercise choice and control over their lives. EVIDENCE: This home is commended for its full activity programme. All staff are involved in the running of activity groups throughout the day. On the day of this inspection group activities observed were darts, bingo, quiz, bowls and an individually designed activity to encourage dexterity, concentration and determination. Residents confirmed that this level of activity is offered every day. Residents are also taken out for drives or walks to the local shops. There is regular entertainment brought into the home and regular tea parties for celebrations. The activity records are detailed and colourful, including drawings, examples of quizzes used and photographs. This is a good record available for residents and their families to look back at together to remember an event they have enjoyed. Staff interaction with residents at these times was very good, with all getting involved in the activities and making it a good experience for all. Residents involve themselves in the activities and evidently enjoy these group activities. Some residents choose to spend some of their days in their bedrooms, watching TV, listening to music, reading etc, and this too is supported. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 11 The home has an open visiting policy, and can provide meals should this be required also. Staff were observed welcoming relatives upon their arrival, with offers of beverages and information offered when requested. Residents confirm that visitors are welcomed at all times. A discussion was held with the Manager about focussing on good practice in relation to the maintenance of individual’s existing skills and independence to all areas of the residents’ lives. This will ensure that residents do not lose essential skills and build upon current skills of independence they already have. Examples of this are around residents being able to serve their own beverages during the day. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 12 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, 18 Residents and their relatives can be confident that complaints are taken seriously and that residents are sufficiently protected from abuse. EVIDENCE: The home has robust and detailed procedures in relation to both complaints and the Protection of Vulnerable Adults from Abuse. The Complaints procedure is displayed on the notice board in the entrance hall of the home and is also included in the Service User Guide. The Manager has in place records for any comments and complaints however informal. These records demonstrate that all such comments are taken seriously and dealt with effectively. From discussions with the Manager, it is evident that she sees this process as a learning opportunity. The home has received one formal complaint since the last inspection visit, via the CSCI. This complaint was in relation to residents care and hygiene. The complaint was fully investigated and found to be not upheld. The Protection of Vulnerable Adults from Abuse procedure is discussed with staff at the time of their induction and all staff have watched the Department of Health’s “No Secrets” video presentation. The Manager is aware of the local “Alerters Guide and Policy” in relation to the reporting and dealing with all allegations of abuse and has reviewed the home’s policy to reflect this. All staff attended some formal training in relation to the Protection of Vulnerable Adults from Abuse in July 2005. In August 2005, the Manager initiated and was the lead investigator in a POVA investigation in relation to a staff member’s conduct. This process was dealt with professionally, promptly and adequately and led to a referral being made to the Department of Health’s Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 13 POVA list. The member of staff concerned has been accepted onto this list and this should prevent them from working in the care sector in the future. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Continual investment is significantly improving the appearance of this home, and should it continue it would create a pleasant, comfortable and safe environment for residents. EVIDENCE: The Owner has put a significant amount of money into the home for the purpose of improving the environment to the benefit of the residents. The main hallways have recently been decorated and now offer a bright and modern feel to the home. One bathroom has been completely refurbished. Others need new bathroom furniture and need updating in relation to the tiling and decoration. Several bedrooms have been redecorated and provided with new furniture and have matching bedspreads and curtains etc. Some bedrooms have been recarpeted. There remain a number of bedrooms that are need of updating in terms of decoration, furnishings and furniture to bring them up to a standard in keeping with some other parts of the building. With some, this just means Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 15 ensuring that furniture pieces are matching and bedding, carpets and curtains are all matching in terms of colours. The homes annual development plan states that two bedrooms will be completely refurbished in May and August 2006. It is disappointing that a little more is not planned given that the owner stated her intention to focus on this area when met at the last inspection visit. The home was found to be clean and hygienic throughout and free from odours. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 Residents are protected by the homes recruitment policies and practices and staff are trained and competent. EVIDENCE: The home has a robust recruitment policy and procedure. Personnel records observed at the last inspection visit were found to be complete. The Manager now obtains Protection of Vulnerable Adults (POVA) first checks for newly recruited staff and these were evidenced in staff records. Subsequent Criminal Record Bureau (CRB) checks have been obtained for all staff also. As mentioned under Standard 18, the Manager has successfully been through the process of referring a member of staff onto the POVA list for exclusion from working in care. Staff in the home have received good training. Staff training files include individual training profiles indicating training attended, when this is required to be updated and further training required. Recent training provided for staff includes; POVA, Fire Safety, Manual Handling, Medication Administration, Food Hygiene, Infection Control, Health and Safety and Understanding Dementia. Planned training in the near future includes Diversity and Equality. Four staff have obtained NVQ’s to level 2 and one is currently undertaking to NVQ Level 3. The registered manager has completed an NVQ Level 4 in care and is undertaking the Registered Managers Award. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 17 Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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): 33 The Manager and Owner have a clear development plan and vision for the home. However, this is not currently communicated to residents, staff and relatives. EVIDENCE: The Manager has collected a number of questionnaires from residents, relatives, staff and other visitors, and intends to extend this to other visiting professionals. Regular resident and staff meetings are held. There are adequate systems and records in place for obtaining feedback from visitors and relatives as well as staff and residents. The Owner and Manager have very clear visions of what the aims and objectives are for the home based on feedback obtained and where they personally would like to see the business going. They are clearly focussed on issues raised by the CSCI as part of the inspection process and are very well informed about the future of residential care and how they meet they future needs. Since the last inspection, they have written an Annual Development Plan and made this available to persons Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 19 who have requested this. However, this needs to be further developed and shared with residents, relatives and other stakeholders. Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 X 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 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 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. 3. 4. Standard OP21 OP24 Regulation 23(2) 23(2) Requirement Timescale for action 30/06/06 7. OP33 24 Complete the refurbishment of the assisted bathrooms and WCs Redecorate and refurnish the 30/05/06 rooms identified during the inspection visit as a matter of priority (Rooms 10, 17, 18, 23, 24, 25) Complete the Quality Assurance 30/05/06 programme and further develop the annual development plan to make it available to residents and other stakeholders 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 Refer to Standard OP21 OP24 OP14 Good Practice Recommendations Refurbish the remainder of the bathrooms and WCs Refurnish, decorate and furnish bedrooms to a good standard in line with some other parts of the home. Encourage and support residents in maintaining skills of independence. DS0000018364.V260034.R01.S.doc Version 5.1 Page 22 Hadleigh Court Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Hadleigh Court DS0000018364.V260034.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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