Inspection on 21/06/05 for Hadleigh Court

This inspection was carried out on 21st June 2005.

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

Hadleigh Court 01/08/07

Hadleigh Court 09/03/07

Hadleigh Court 21/02/06

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 Stanley Road Torquay Devon TQ1 3JZ Lead Inspector Sharon Goldsworthy Announced 21 June 2005 st 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 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 D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hadleigh Court Address Hadleigh Court, Stanley Road, Torquay, Devon, TQ1 3JZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01803 327694 01803 327694 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 D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 March 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 D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was announced and was carried out on a Tuesday between the hours of 10am and 4pm. The Inspector made a tour of the premises, observed some care records and spent some time talking with residents, relatives, staff on duty as well as the Manager and Owner. Despite the Manager making available pre inspection questionnaires to residents and visitors, none were received by the CSCI prior to this visit. Since the last inspection the Manager has become a Registered Manager with the CSCI. What the service does well: What has improved since the last inspection? The Owner has purchased a minibus that is adapted to take wheelchairs. This is a positive addition to the care package. In addition, the following purchases have been made; a new dishwasher, cooker and microwave, a new wheelchair and a number of new beds. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 6 The main hallway, corridors and bathrooms are currently being renovated and redecorated. 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 D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 The homes Statement of Purpose and Service User Guide is good and provides prospective residents with details of the services provided, enabling an informed decision about moving into the home. Resident’s needs are adequately assessed prior to moving into the home. EVIDENCE: The home has a detailed and clear Statement of Purpose and Service User Guide in place, both of which have been reviewed and updated yearly. Some residents were able to confirm that they received a copy of the Service User Guide at the time of their admission. The availability of these records ensure that prospective residents are given information with which to make an informed decision about moving into the home or not. All new residents spoken to confirmed that either they or their relatives were able to visit the home prior to making a decision about moving in. One resident made two visits to the home to spend some time meeting staff and other residents and looking around the home. During these visits a full assessment of his level of needs was completed and this record was observed. It is important that such assessments are completed prior to admission to the Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 9 home, so as the home can make a decision about whether they can meet the needs of the resident and how they intend to do this. Hadleigh Court provides a day care service and offers respite care. Some of its current residents had previously used these services prior to making a decision about moving into the home. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, 10, 11 Resident’s health and personal care needs are being met. EVIDENCE: Care plans were found to be detailed, complete and up to date with the exception of one. All care plans detail the level of care and assistance required for individuals and care records clearly detail where health care (such as GP, District Nursing, Chiropody, Hospital treatment etc) has been provided. Records indicate that the health care needs have been sought regularly and timely. Residents spoken with confirmed that they have received visits from these health care professionals when required and that these visits were arranged in a timely manner. Residents confirmed that they are treated with respect and afforded dignity and privacy is respected. Several residents reported that they spend time during the day in their bedrooms pursuing their own activities. These confirmed that they are left alone, with the exception of receiving beverages and that staff always knock on the door before entering. This practice was observed during the inspection visit. Residents confirmed that the call bell is always answered promptly. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 11 One resident in the home is currently very poorly and is receiving an appropriate level of care from their GP and the District Nursing team. Because of the circumstances, this individual’s spouse is very involved in the day-to-day care and decision-making about the level of care offered. The care plan for this person did not accurately reflect the current level of need, although has been updated regularly prior to a recent deterioration in their health. It is imperative that care plans accurately reflect the current needs of the resident to ensure that an accurate level of care and assistance can be given and that all staff can give this consistently. The home is hoping to provide care for as long as is required with the assistance of the District Nursing service. Medication was found to be stored, recorded and administered as required. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 standard(s) 15 Dietary needs are well catered for with a balanced and varied selection of foods available that meets resident’s tastes and choices. EVIDENCE: The home has a rolling menu that offers sufficient choice and a balanced diet. Residents reported that they are offered a full choice of meals, snacks and beverages throughout the day and that alternatives meals are prepared according to choice or for specific dietary requirements. Residents reported that although there are set meal times, this can be flexible and meals can be taken in bedrooms if they prefer. The main mealtime in the home was observed to be relaxed and unrushed and appropriate levels of assistance were offered affording dignity to those individuals. Meals were seen to be well presented and representing the menu choice on offer. Fresh vegetables and ingredients were used and all dishes are cooked at the home. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 not received any formal complaints since the last inspection visit. 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. The Manager reported that formal training has been sought and it is hoped that this can be provided for all staff in the next few months. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 24, 25, 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. Several items have been purchased for the kitchen, such as dishwasher, microwave and cooker. Several new beds have been purchased and there are plans to purchase others. The main hallways have recently been decorated and now offer a bright and modern feel to the home. One bathroom has been completely refurbished and others are in the process of being refurbished. These rooms need new bathroom furniture and need updating in relation to the tiling and decoration. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 15 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 ensuring that furniture pieces are matching and bedding, carpets and curtains are all matching in terms of colours. The Manager and Owner stated their determination to address this in the next year. There are two bedrooms that have a very strong odour present. It is thought that these odours are in the carpets and possibly the flooring. The Manager reported that these rooms are cleaned daily, although this is not having any lasting effect. The Owner agreed to focus on these two rooms as a priority to eliminate these odours and provide an environment that will eliminate these odours from re-occurring. The remainder of the home was found to be clean and hygienic throughout. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Staffing levels and competencies are sufficient to meet the needs of the residents. EVIDENCE: The Manager is present generally Monday to Friday, although does work additional hours as required covering vacancies on the rota. The home now employs a senior carer who is also present throughout the week and manages the day-to-day care of the residents. The staff rota indicates that there are four staff on duty in the morning and three in the afternoon. The Manager and Senior Carer hours are additional to this. Staff have adequate breaks between shifts and at least one full day off per week. From observations on the day of the inspection it is apparent that there are sufficient levels of staff to provide the required level of care. The Manager is aware that the staffing levels may well need to be reviewed according to the needs of one resident who is currently very poorly. There are currently two members of staff on duty at nights and additional ancillary staff for cleaning, cooking and a handyman. The home has a robust recruitment policy and procedure. Personnel records observed on the day of this inspection visit were found to be complete as required, with the exception of Protection of Vulnerable Adults (POVA) first checks for newly recruited staff. The Manager reported and was able to demonstrate that these checks had been requested, however, due to an administration failure, these checks had not been received by the Manager and as such had been overlooked and the members of staff started work. It is Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 17 imperative that the POVA list is consulted prior to bringing any new member of staff into the home to ensure the safety of residents. Subsequent Criminal Record Bureau (CRB) checks have been obtained for all staff. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 38 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. The health and safety of residents and staff are adequately protected. EVIDENCE: The Manager has devised and has collected a number of questionnaires from residents, relatives, staff and other visitors. 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. They now need to clearly record these thoughts and findings in a way in which it can be shared with residents, relatives and other stakeholders. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 19 The home does not manage or get involved with any monies for residents. It is expected that any monies required by residents is managed personally, or where this is not possible the residents relatives or representatives do this. All health and safety records were observed on the day of this inspection visit and found to be accurate and up to date. There are ongoing visits from the Environmental Health inspector who is working with the home on some specific issues relating to food hygiene. However, the Manager was able to demonstrate that the home have taken steps to address and meet any outstanding requirements and recommendations set at the last visit of March 2005. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 2 x 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x 3 x x 3 Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? 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. Standard 7 18 Regulation 15(2) 13(6) Requirement Care plans must be kept up to date, clearly indicating the current level of need. All staff must receive formal and certificated training in relation to the Protection of Vulnerable Adults from Abuse Complete the refurbishment of the assisted bathrooms and WCs Redecorate and refurnish the rooms identified during the inspection visit as a matter of priority (Rooms 4, 24, 11) Take appropriate steps to eliminate odours to bedrooms 3 and 22. Ensure that POVA first checks are obtained for all new staff before commencing work in the home. Complete a development plan and make it available to residents and other stakeholders Timescale for action 30/7/05 30/10/05 3. 4. 21 24 23(2) 23(2) 30/08/05 30/09/05 5. 6. 26 29 16(2)(k) 13(6) & 18(1) 24 30/7/05 30/6/05 7. 33 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 22 No. 1. 2. 3. 4. Refer to Standard 21 24 24 27 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. Supply net curtains as requested by the resident to room 2 to ensure an appropriate level of privacy. Continue to review the current staffing levels according to individuals increasing needs. Hadleigh Court D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton 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 D54-D07 S18364 Hadleigh Court V224171 210605 Stage 4.doc Version 1.30 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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