Inspection on 09/03/07 for Hadleigh Court

This inspection was carried out on 9th March 2007.

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 21/02/06

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 9th March 2007 09.30 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.V326670.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. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadleigh Court Address Hadleigh Court Stanley Road Torquay Devon TQ1 3JZ 01803 327694 01803 327771 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 Vacancy 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.V326670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 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, as well as a newly fitted stair lift to the main stairway. 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. 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, adjacent to a local park and near to local shops and other amenities in St Marychurch and Babbacombe. The fee level for this home ranges from £300 to £650 – dependent on the level of need. The home’s Statement of Purpose is given to all prospective residents and in addition can be obtained from the home’s office. It is the manager’s intention to re-issue all residents and their representatives with an updated copy of this document in the near future. Hadleigh Court DS0000018364.V326670.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 and took place over two days – Friday 9th March and Monday 12th March 2007. The new manager spent some time with the inspector, as did the owner and time was spent observing care practice, talking to a sample of residents, touring the premised and viewing a sample of records. There is a new acting manager in position currently, who has put in an application to the CSCI for registration. The owner is present most days as support for the new manager. Much of the staff team has remained stable, although there have inevitably been some changes to the staff team in the last year as would be expected. The home is generally well maintained with a continual programme of improvement works underway all of the time. A number of pre-inspection surveys were received from staff members, resident’s representatives and health and social care professionals who visit the home regularly. In addition, staff members, visitors and residents were spoken to on the days of this inspection visit. All were happy with the level of care provided and the home in general. Positive comments were received from residents about the staff and new manager and the home. Some staff members, one visitor and one social care professional made particular mention to the good level of training offered at Hadleigh Court. Some staff members made particular mention to the good level and range of activities offered including the ability to take residents out to the park, on drives and shopping most afternoons. What the service does well: There is a good level of activities and outings offered to residents each day. This provides residents with a good level of stimulation and social interaction, as well as maintaining links with the local community. Residents physical health and personal care needs are met, with residents being well presented, clean and well-laundered clothing and regular health care being accessed when required. This is also important for residents’ emotional well being and feelings of self worth. Medication systems are well managed, monitored, stored and recorded appropriately. This ensures the residents are not placed at risk of harm or abuse. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 6 Residents, who were able, reported that there is always a good selection of foods that is fresh and nutritious. There is a choice of menus, alternative dietary requirements are catered for and there are good monitoring systems in place of residents’ dietary requirements and intakes. This is particularly important for those residents who have communication difficulties or for those residents who are physically poorly and requiring additional monitoring or care. There is ongoing maintenance and refurbishment of the home. This has been continual and there is an ongoing maintenance plan for the refurbishment of further areas including a bathroom and further bedrooms. What has improved since the last inspection? What they could do better: The home’s previously registered manager resigned in November 2006, leaving the deputy manager to step up into the position of acting manager. Unfortunately, it is reported that there was insufficient time for the previous manager to handover to the then deputy manager, and as such some aspects of the administration system has not been maintained to the required standard. The acting manager is aware of the areas of deficiency, but does not feel as though she has to this point had the time to fully explore these areas. It is hoped that following this inspection, the acting manager is now fully aware of her responsibilities and has prioritised those outstanding areas for attention. Care staff were observed in care practice for the duration of a mealtime. There were some good examples of good care practice, given by one member of staff in particular and to those residents who are more independent. However, some examples of poor care practice given to residents with a greater level of need (in particular those with dementia and those with little communication) was observed. Staff members were focussed on care related tasks, but there was little communication and social interaction and little attention to those residents who needed additional time, support and attention. These observations were brought to the attention of the acting manager who Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 7 intended to raise these issues with staff at a forthcoming meeting and look into obtaining a dementia care course for all staff. There remain some outstanding requirements in relation to the refurbishment of some identified bedrooms and bathrooms. The owner stated her intention to address these – and had made some progress in this area. A discussion took place with the acting manager in relation to the front door bell and call system alarms. These sound in the dining room/entrance hall. They are very loud and during the mealtime observation showed a great deal of disturbance to residents, in particular those who have dementia. One relative responding to the pre-inspection surveys also mentioned this as an issue of concern. One member of staff did not have a current CRB, POVA check or reference from her previous employer. Two staff did not have POVA checks before commencing employment. None of these staff members had received supervision. Some staff files contained supervision and appraisal records, induction programmes and training profiles, but not for all and supervisions and appraisals have now fallen behind. The current induction and foundation programme used in the home, is one devised by the previous manager. Whilst it covers most areas it does not follow the National Training Organisation (NTO) induction and foundation standards of care. 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. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most prospective residents are given the information required to make an informed decision about the home in which they may wish to live. EVIDENCE: The home has a clear and comprehensive Statement of Purpose and Service User Guide. The acting manager was able to show the inspector an additional updated sheet that had been produced ready to be replaced in the Statement of Purpose. She confirmed that this document was given to all new residents and/or their representatives prior to their admission. However, this updated information had not been given to all current residents and their representatives. The acting manager suggested that she would re-issue the full documents to all current residents and their representatives and give the updated information to all placing authorities. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 10 The acting manager was able to show records of pre-admission assessments for a sample of residents currently in the home. These records were seen to be appropriate and complete, and had been completed by the acting manager at a visit to the prospective resident at their previous address or care setting. However, these records were not in place for all recently admitted residents. The acting manager confirmed that these were residents who had been admitted on emergency placements and she had not been given any information in terms of assessments of needs. There is currently no format in place on which the acting manager can record her decision to accept a prospective resident or not. She was advised to devise such a record or letter as required under the Care Homes Regulations 2001. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are clearly set out in care plans and needs are met. 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 recently replaced the system on which care plans and daily care records are recorded. There are additional records in place for the monitoring of falls, behaviour causing concern or potential risk of harm to self or others, weight records and food and fluid intake. Risk assessments are complete and daily records are complete and reflect the current level of needs and level of monitoring. However, there is a need to expand on some areas of the care plans to provide more exact level of care required where there is a need and risk assessments and care plans need to evidence that they are reviewed, by whom and amended where required. The acting manager and owner were advised to evidence that they regularly review all care documents Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 12 and ensure that records are regularly reviewed, kept up to date and appropriate language and level of detail are recorded. Records sampled evidence that residents’ health care needs are met when required and when appropriate. Residents spoken to confirmed that they have access to health care (such as District Nurses, GPs, chiropody, dental and optical care) when required. On the day of the inspection a resident was visited by a mental health social worker for assessment and was admitted to an assessment unit for additional review and monitoring of her current mental health and medication needs. A complaint was made by a representative of a day care service user recently, who felt that her mother’s personal care and chiropody care needs had not been met. The acting manager carried out an investigation and found the complaint partly substantiated. Systems have now been improved for day care service users in line with her findings and will be kept under review by the home, as this is not come under the CSCI remit for inspection. The medication system was found to be neatly and appropriately stored and recorded and some administration of medications was observed, although little on this occasion. On the day of the inspection visit, alterations were being undertaken to the medication storage area, to provide a pigeonhole for each resident’s medications not held in blister packs. This will serve to reduce the risk of medication error and make the administration task for staff a little easier when needing to look for additional medication required. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ general lifestyle and social activities is encouraged to meet their needs. 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. Residents’ receive nutritious, well-balanced meals with specific dietary requirements met. EVIDENCE: This home is commended for its full activity programme. All staff are involved in the running of activity groups throughout the day. Activities reported to have been continued are 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 home previously had an activity records that was detailed and colourful, including drawings, examples of quizzes used and photographs. This was a good record available for residents and their families to look back at together Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 14 to remember an event they have enjoyed. However, on this occasion, activity records had not been completed since January and were very short, non descriptive and did not include drawings, photographs etc. The acting manager stated her intention to address this with staff. Staff interaction with residents at these times is 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. 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. At the last inspection, 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 would 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. The acting manager confirmed that following this a small number of residents had been offered and had been given a kettle in their rooms (this was observed during a tour of the premises). However, there remain concerns about a number of residents felt to be at risk of managing a teapot for example at the table. A discussion was held about the need to still offer these residents the experience of choice and ability to, for example, put in their own milk and sugar or pour their own glass of water of put on their own sauces, gravy etc with the support of care staff. The home has a rolling menu, which offers the residents a good level of variety and choice. All meals are served with three courses and tea and coffee to follow. The mealtime on the second day of this inspection was observed. The residents who are more independent and who are not confused received a good level of service, being offered choices, receiving their meals unrushed and having the opportunity to serve their own drinks etc. However in the majority of cases where residents required assistance with feeding, the level of care was not satisfactory, with the exception of one member of staff on duty. Staff were observed assisting residents with feeding, sat on tables by their sides, but no interaction other than the physical task of feeding the resident. One member of staff, when the meal had finished, just stood up and walked off with the empty bowl, not explaining to the resident that the meal had finished or any interaction, such as checking if she enjoyed the meal, if she had had enough or would like some more for example. A similar experience was given to another resident, only this time the member of staff kept getting up and walking off to observe another resident who kept going to the front door. Whilst it may have been important to observe this other resident, the member of staff made no comment or apology to the resident to whom she was Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 15 assisting with her food. Another resident, sat in the lounge, was observed being given a bowl of pudding on the table in front of her, with no explanation as to what the pudding was or even asked if she wanted or liked it. The resident ate one spoonful of pudding and pushed the bowl away. A member of staff walked past taking the bowl away as she continued to walk away, saying “have you finished”. She did not stay to check with the resident why she had not eaten it or offered an alternative – as there was every possibility she did not like it. These observations, as other examples of care practice, were given to the acting manager. She stated her disappointment and her intention to address this with the staff team at a forthcoming staff meeting. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents and their relatives can be confident that complaints are taken seriously and acted upon where required and procedures and training in place in place protect residents 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 acting manager has in place records for any comments and complaints however informal, although these have not been kept up to date recently. The records previously held demonstrate that all such comments are taken seriously and dealt with effectively. The current acting manager has received one formal complaint via the CSCI. This complaint was in relation to residents personal and chiropody care. It was subsequently found that this person was a day care client and not a resident as indicated in the original letter of complaint. However the acting manager investigated this complaint and found it to be partially upheld. A letter was sent to the complainant detailing her findings and actions for addressing where issues had not been sufficiently addressed. During this inspection visit, a further complaint was sent to the CSCI, which in turn has also been forwarded to the acting manager for investigation. The acting manager was already prepared with a report already having been prepared in preparation for Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 17 receiving this complaint from a short-term respite client. The complaint is still under investigation at the time of writing this report. 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 acting manager is aware of the local “Alerters Guide and Policy” in relation to the reporting and dealing with all allegations of abuse and on the day of the inspection replaced the home’s procedure with this, as it was felt to be more appropriate and current. Five of the current staff team have attended some formal training in relation to the Protection of Vulnerable Adults from Abuse. It is hoped that the remaining staff team members will attend this training also – but is awaiting a date from the local authority who arrange this training event. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 18 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, 22, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Since the last inspection the owner has fitted a stair lift to offer an alternative to the lift shaft, redecorated and refurbished two bedrooms, new beds have been purchased for three bedrooms, new furniture has been purchased for the dining room, new table cloths have been purchased, new keypad entry and exit systems to more doors have been fitted, wall mounted air fresheners have been fitted throughout the home, new telephones for the home have been purchased and lockable storage units for the storage of records have been purchased. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 19 Some bedrooms have been redecorated and provided with new furniture and have matching bedspreads and curtains etc. Some bedrooms have been recarpeted in the last year. 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. It is hoped that this continues to remain in focus. A discussion took place with the acting manager in relation to the front door bell and call system alarms. These sound in the dining room/entrance hall. They are very loud and during the mealtime observation showed a great deal of disturbance to residents, in particular those who have dementia. One relative responding to the pre-inspection surveys also mentioned this as an issue of concern. The home was found to be clean and hygienic throughout and free from odours. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 20 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. The home currently has sufficient numbers of staff. Some staff would benefit from further training in order to meet residents needs fully. Recruitment practices are currently poor and potentially place residents at risk of harm or abuse. EVIDENCE: Staffing levels appear to be adequate to meet the needs of the current resident group. The acting manager was seen to be keeping this under close review in terms of two residents whose needs had recently increased and where staff were finding it increasingly difficult to manage their needs. Assistance was sought from the social and health care professionals and the resident’s needs were assessed and treatment advised. Rotas indicate that there are currently four care staff and one senior on duty in the mornings and three care staff and one senior on duty in the afternoons. There are two waking night members of staff. In addition, there is a cleaner and laundry assistant, on duty Monday to Friday and a cook and kitchen assistant seven days a week. There are two support workers who assist with teatime in the evening, a driver and a gardener. The acting manager is present in the home Monday to Friday – but is on-call at nights and weekends. The home employed a deputy manager until the week of this inspection, when unfortunately this employment had to be terminated. The owner and acting manager are currently discussing the Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 21 options of re-advertising this post either internally with the offer of training or externally. The acting manager is intending to purchase identification badges for all staff in the next few weeks, which would assist both residents and visitors in identifying staff members and their position in the home. A sample of recruitment records were viewed, all of whom were recently recruited staff. One member of staff did not have a current CRB, POVA check or reference from her previous employer. This member of staff was in a senior position in the home. Two further staff did not have POVA checks before commencing employment and one of these has no recorded induction in place. None of these staff members had received supervision. Some files had recent photographs of staff members, but not all. Some staff files contained supervision and appraisal records, induction programmes and training profiles, but not for all and supervisions and appraisals have now fallen behind. A discussion was held about the need for such records to be maintained and for appropriate levels of checks (i.e. POVA, CRB and previous employer references) to be obtained, so as residents are not placed at unnecessary risk of harm or abuse in the future. The current induction and foundation programme used in the home, is one devised by the previous manager. Whilst it covers most areas it does not follow the National Training Organisation (NTO) induction and foundation standards of care. The acting manager was advised to obtain copies of these standards and maintain a record of induction and foundation training for all staff in line with these standards. The home has an ongoing training programme (of which was praised by staff and one social care professional). Recent training includes; manual handling, medication procedures, fire safety and evacuation, POVA, NVQ’s (level 2), infection control, safety compliance. Training planned for the next year includes; POVA, dementia care, fire safety, manual handling, first aid, food hygiene, health and safety and continuation of NVQ training. As mentioned earlier in this report staff care practice in caring for those residents who have dementia or communication difficulties was poor. A discussion was held with the acting manager, that when planning dementia training for staff, to look at more in depth and continual training programmes, rather than a basic one day information dementia course, that will not serve to improve understanding and communication with persons with dementia and in turn improve care practice in this area. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 22 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, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not currently managed by a registered manager. The Owner has a clear development plan and vision for the home. However, this is not currently communicated to residents, staff and relatives. Not all staff are appropriately supervised. Residents are protected in terms of the health and safety of the premises, policies and practices. EVIDENCE: The previously registered manager resigned in November, leaving the deputy manager to take up the post of acting manager. Unfortunately, it is reported that there was insufficient time for the previous manager to handover to the then deputy manager, and as such some aspects of the administration system has not been maintained to the required standard. However, the acting Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 23 manager does seem aware of her responsibilities as a manager and is keen to learn and improve on the areas of concern identified at this inspection. She has recently submitted an application to register with the CSCI. This application will be considered for her fitness to remain in post as a manager at Hadleigh Court and be registered as a care manager with the CSCI. At the last inspection, the previous manager had collected a number of questionnaires from residents, relatives, staff and other visitors, and intended to extend this to other visiting professionals. However, this was over a year ago, and the acting manager was advised to carry out this process again now. 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 has 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. At the last inspection an Annual Development Plan had been written and made available to persons who have requested this. However, it was advised then that this needs to be further developed and shared with residents, relatives and other stakeholders, which it still has not. A sample of records were sought in relation to the health and safety standards and the following was observed; • Fire safety records were found to be up to date, as were fire safety checks. The fire risk assessment was due for review in February 2006, and there was no evidence to suggest that this had taken place. Fire safety training has taken place with all staff and this included evacuation procedures. • COSHH assessments and information records were found to be in place. The acting manager is in the process of obtaining up to date and new product information leaflets from a new supplier. • Policy and procedure files are in place in the office and have been previously inspected. However, many of these are now due for review. • Accident records were in place, but in two different books – one of which is now obsolete. The acting manager was advised to stop using this book. There were a number of accidents that have necessitated medical assistance being requested. The CSCI had not been informed of some of these events – although had of some. • There were no Regulation 26 visit records in the home. The acting manager advised that to her knowledge the owner does not carry out such formal visits – but is in the home most days. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 24 Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 25 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1) Requirement All prospective residents are assessed by the acting manager or other suitably qualified or suitably trained person, prior to a placement being offered in the home. A record of these decisions should be kept. All records must be kept up to date and regularly reviewed and amended as required. Ensure that residents’ wishes and feelings are taken into account at all times and choices offered and that residents are treated with dignity and respect at all times. Care practice at meal times needs to improve in relation to the care of residents with higher levels of need. Complete the refurbishment of the assisted bathrooms and WCs Redecorate and refurnish the rooms identified during the last inspection visit as a matter of priority (Rooms 10, 18, 23, 24, 25) (Previous timescale given – 30/5/06) POVA, CRB and the most recent employer reference must be DS0000018364.V326670.R01.S.doc Timescale for action 01/04/07 2 3 OP7 OP15 15(2) 12(1),(2), (3),(4) 01/04/07 12/03/07 4 5. OP21 OP24 23(2) 23(2) 30/06/07 30/06/07 6 OP29 19 12/03/07 Hadleigh Court Version 5.2 Page 27 7 8 9 OP29 OP29 OP30 18(2) 18(2) 18(1) 10. OP33 24 sought for all staff prior to employment. Obtain an appropriate induction and foundation standards induction package Ensure that all new staff complete an induction and foundation training package Ensure that all staff attend a detailed training course in relation to caring for persons with dementia. Complete the Quality Assurance programme and further develop the annual development plan to make it available to residents and other stakeholders Fire risk assessments to be reviewed and updated where necessary The owner must carry out formal visits to the home with records kept for inspection. 31/03/07 30/03/07 30/09/07 30/05/07 11 12 OP38 OP38 23(4) 26 31/03/07 31/03/07 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 3 4 5 6 7 Refer to Standard OP7 OP7 OP12 OP14 OP16 OP18 OP21 Good Practice Recommendations Expand on “assistance required” in care records. Ensure that appropriate and professional language is used when describing residents’ care in particular in daily records in addition to other documentation. Re-instate the activity record as before and ensure that this is kept up to date. Continue to encourage and support residents in maintaining skills of independence. Re-instate comments and suggestions records Remaining staff members to attend POVA training as the date becomes available. Refurbish the remainder of the bathrooms and WCs DS0000018364.V326670.R01.S.doc Version 5.2 Page 28 Hadleigh Court 8. 9 10. 11 12 13 OP24 OP29 OP29 OP36 OP38 OP38 Refurnish, decorate and furnish bedrooms to a good standard in line with some other parts of the home. Provide identification badges for all staff as planned Keep recent photographs of all staff on records. Ensure that all staff receive supervision a minimum of six times a year and appraisals once yearly. Review all policies and procedures and up date where required. Ensure that the CSCI are informed of all accidents requiring medical attention. Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Hadleigh Court DS0000018364.V326670.R01.S.doc Version 5.2 Page 30 - 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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