Inspecting for better lives Random inspection report
Care homes for older people
Name: Address: Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU The quality rating for this care home is: The rating was made on: one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Jane Lyons Date: 1 3 1 0 2 0 0 8 Information about the care home
Name of care home: Address: Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU 01469572514 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Michael Thomas Bailey care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category 0 Over 65 38 Conditions of registration: Date of last inspection Brief description of the care home Hadleigh House provides comfortable, homely accommodation for up to 38 people over the age of 65. The home is situated close to all amenities in Immingham. It has pleasant gardens; its own car park and is on a bus route. The home is a two-storey building with access to the first floor via stairs and a passenger lift, it is well maintained in terms of decor and furnishings. There are 32 single bedrooms and 3 shared, en-suite facilities are provided for the five new single bedrooms on the first floor. There are four bathrooms and a shower room with separate WC facilities provided on each floor. The home provides 3 lounges and a pleasant dining room for people to use. The rear garden has been landscaped and an attractive courtyard area provided, with seating and shade for individuals and their visitors. Ample car parking space is provided. The home is owned by Mr M Bailey. There is no registered manager currently in post. Weekly fees are between three hundred and sixty one pounds and Care Homes for Older People Page 2 of 11 four hundred pounds. The home operates a system whereby the fees include a third party contribution of fifteen pounds. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody and escort fees. Information on the service is made available to prospective and current people who use the service via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available in the lounge area of the home. Care Homes for Older People Page 3 of 11 What we found:
The staff have worked hard to make improvements to the care plans since the last inspection visit.The plans are more detailed to direct staff on the actions they need to take to meet the needs of the people they are caring for and are more person focused with more information about an individuals abilities and personal preferences.The care plans are regularly reviewed to keep the information up to date.Three of the senior care staff have accessed training in care planning with more courses scheduled. Earlier in the year the manager received a letter from the complaints department at North East Lincolnshire Care Trust Plus,complimenting the staff on the quality of the care documentation they had provided during a complaints investigation. There was good evidence in the care records that risk management of individuals health needs had improved greatly,many of the care staff had accessed training in this area.The home had worked closely with community health professionals and risk assessments were in now place for areas such as nutrition,falls,pressure damage and moving/ handling,care plans had been developed to support any areas of high risk identified. Systems to monitor peoples weight properly were now in place and records confirmed that staff followed up any concerns. There was good evidence in records of staff meetings and supervision records that staff had received direction from the management around accessing emergency support for individuals following falls and accidents in the home. Accident records were checked for two individuals who have a history of falling,these showed that the staff had accessed emergency support where appropriate and care records were detailed and described all follow up action and care support required.The home has accessed the support of the community falls coordinator who has visited the home and worked with staff to review mobility equipment,environmental changes and risk management strategies.Overall there is good evidence that the home has made improvements to ensure that the safety of people living in the home is more fully protected and appropriate action is taken following accidents in the home. Pharmacy advisors from the local Care Trust Plus visited the home in September to look at the medication systems in place and made a number of recommendations around improvements needed to the recording systems in place. At this visit there was good evidence that the manager had taken action in a number of areas in respect of the recommendations made and some of these include: the introduction of a system of medication audits where she checks all administration records weekly and carries out a full audit of medication on a monthly basis,records of these audits should be more detailed to evidence any action she has taken and changes made.The manager has also introduced a system of supervised medication rounds where she is accompanying all senior staff on at least four medication rounds to ensure they are competent in their administration and recording practices. Improvements were seen to records when prescription changes had been made and written confirmation from the G.P. was seen to be in place.The manager confirmed that medication refresher training for senior staff is being arranged and the policies and procedures are currently being reviewed to more clearly support the homes practices.Medication records checked showed that improvements had been made with the standard of administration and transcribing Care Homes for Older People Page 4 of 11 (hand writing)recording which better ensures that people receive the correct medication at the correct times. People spoken to during the visit said that the manager and staff were very approachable and always dealt with any issues they raised.Checks on complaint records showed that improvements had been made to the standard of complaints investigation and recording of outcomes.The complaints department at the local Care Trust Plus told us that the home had worked very positively with them during a recent complaints investigation.This department have also offered their continued support to the management of the home to oversee future handling of complaints. People who use the service said they were very happy and satisfied with the facilities at the home, one commented My room is very comfortable, I was able to bring in my own bed, my son thinks my room is like one in The Hilton, Im very happy here. A short tour of the home showed that all areas were very clean and tidy,odour control has been managed more effectively which better promotes peoples comfort and dignity. People spoke very highly of the staff team and said that staff always listened to them and were very kind and helpful.Comments included The staff are wonderful,everyone is so kind, they cant do enough for us. Earlier in the year the registered provider took the decision to reduce staffing levels based on the number of people living in the home,concerns were raised to us by community health and social care teams.Staffing levels have since been increased but not to the original numbers, during the visit the manager provided figures from the Residential Staffing Forum calculations which are based on the dependency levels which show that there is currently a shortfall of 40 hours per week. People spoken to commented that the staff were very busy but always found time for you.Observations of the routines showed that staff were busy all day, staff spoken to said that they had less time to spend with people and could not take them out as much, some felt that they had to rush peoples care at times. Improvements have been made with the staff training programme.The manager keeps an overview training plan, she confired that staff were now up to date with mandatory training in fire safety, food hygiene and courses in moving/ handling would be complete by the end of the month.This was supported by information held within peoples files and confirmed by staff. Staff spoke about undertaking other courses such as dementia, infection control, health and safety and safeguarding. Records showed that new staff have completed induction training to ensure they understand the needs of the people they are looking after and are competent in their care practices. Records showed that more than 50 of care staff now hold an NVQ II care award. The manager of the home Marie Woodley gained her registration with the commission in August 2008. It is clear from this inspection visit that the manager has worked very hard to improve many of the management and administration systems in the home since her appointment, with very positive results in areas such as the care records, staff training, complaints management and staff supervision. There was evidence that fifteen of the sixteen requirements issued at the previous inspection visit had been fully actioned. The manager at the home is committed to ensuring that people staying in the home are consistently well cared for, safe and happy. People, staff and relatives said they were all happy to approach the manager at any time for advice, guidance and to look at any issues. One person who uses the service said I am so happy Marie Care Homes for Older People Page 5 of 11 got the job, shes just the right person and discussions with staff indicated that the manager is popular and well respected. All staff said that they now receive regular supervision and regularly meet up with their manager to discuss ways of working, checks of records confirmed this. The manager has purchased new policies and procedures for the home, these are generic and the manager has started to review and personalize them to the homes practices. There is good evidence that the manager has put in place a number of quality monitoring systems and people are more regularly consulted about the services at the home however the programme now needs to be formalised. Some of the homes records are audited but records of findings and any action taken needs to be kept. Surveys have been sent out to people who use the service and relatives, results of the surveys need to be analysed and action plans drawn up to improve areas of deficiency if identified. Findings from the surveys and audits need to be published in the home and in the service user guide. A representative for the responsible individual visits the home on a monthly basis. An annual development plan needs to be produced which should detail the direction the service is going and the improvements the home is planning to make over the next twelve months. People who use the service and their relatives meet with the management of the home. These quality assurance systems will help to ensure that the service is operating in the best interest of the people who live there. The homes fire safety records showed that the fire safety systems were regularly checked. A fire risk assessment was in place and although brief it covers all main areas and the front door lock has now been included. Improvements were seen with the management of bed rails in the home. New risk assessment documentation had been introduced which is more detailed and will provide more protection for people using this equipment. What the care home does well: What they could do better:
The manager has started to monitor the quality of services the home provides with Care Homes for Older People
Page 6 of 11 some audits, surveys and now holds regular meetings with the people who use the service and staff.However this programme needs to be more formalised so the management can clearly demonstrate that the home is operating in peoples best interests. The manager needs to complete a staffing review to ensure that appropriate numbers of staff are always available to meet the needs of the people using the service. Improvements have been made to the recording of medication administration and to the transcribing (hand writing the prescriptions on the medication records) although some further improvements are needed.This will make sure that people receive the right medication when they need it. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 11 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set.
No. Standard Regulation Requirement Timescale for action 1 33 24 The registered person must 10/01/2009 ensure that the quality assurance programme is restarted and maintained which is supported by an annual development plan. This will show how the home has consulted with people who use the service, their representatives, staff and stakeholders to influence the running of the home. Previous timescales 30/06/06, 30/11/06, 30/06/07 and 30/05/08 not met. Timescale extended. Care Homes for Older People Page 8 of 11 Requirements and recommendations from this inspection
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 27 18 The registered person must 09/01/2009 ensure that there are appropriate numbers of staff rostered to meet the dependency needs of the people who use the service. This will ensure that peoples needs are properly met in a timely manner. 2 33 24 The registered person must 10/01/2009 ensure that the quality assurance programme is fully maintained which will inform an annual development plan This will show how the home has consulted with people who usethe service, their representatives, staff and stakeholders to influence the running of the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No. Refer to Standard Good Practice Recommendations 1 9 The manager should consult with the pharmacy provider to provide more pre- printed medication administration
Page 9 of 11 Care Homes for Older People records which would reduce the ammount of transcribing for staff and reduce risk of error. 2 9 The manager should complete the review of medication policies and procedures to make sure they clearly describe the homes practices. Care Homes for Older People Page 10 of 11 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 11 of 11 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
