Inspection on 12/07/06 for Hadley Lawns

This inspection was carried out on 12th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hadley Lawns 08/05/07

Hadley Lawns 07/02/06

Hadley Lawns 16/05/05

Hadley Lawns 01/11/04

Hadley Lawns 05/05/04

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

CARE HOMES FOR OLDER PEOPLE Hadley Lawns Kitts End Road Barnet Hertfordshire EN5 4QE Lead Inspector Daniel Lim Key Unannounced Inspection 12th July 2006 02:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hadley Lawns DS0000010449.V303092.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. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadley Lawns Address Kitts End Road Barnet Hertfordshire EN5 4QE 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) 020 8449 0324 020 8449 9097 hillyersupa@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Vacant Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five specified service users who have dementia may remain accommodated in the home. The home must advise the registering authority at such times as any of the specified service users vacates the home. 7th February 2006 Date of last inspection Brief Description of the Service: Hadley Lawns Care Home is owned by BUPA and is registered to care for a maximum of forty-four older people. The home provides personal care and nursing care. The home aims to maintain the high standards of care and comfort in a way that meets personal needs. The home is a two storey detached house. There is a lift between the ground and first floors. There are forty-four bedrooms located on the ground and first floors. All bedrooms are single and have en-suite facilities. The ground floor has a reception area, managers office, a staff room and kitchen. There is also a large dining room, two communal lounges and service users bedrooms. On the first floor there is another large communal lounge / diner, kitchenette and residents bedrooms. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is about a mile from shops and community facilities located in High Barnet. The fees charged by the home range from £700 - £950 each week. The provider must make information about the service available (including reports) to service users and other stakeholders. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 12 July 2006 and 21 July 2006 and took a total of five hours to complete. The inspector found that the overall quality of care provided was of a high standard. During this inspection, the inspector was accompanied by the acting head of care of the home (Ms Deborah Nakato) and the acting manager / regional support manager (Ms Kerry John). The inspector was able to interview three residents and three relatives. The feedback received from them indicated that they were satisfied with the care provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, treatment room, laundry, kitchen, gardens and communal areas were inspected. Three staff on duty were interviewed on a range of topics associated with their work. Staff records, including supervision records, evidence of CRB disclosures, references and training records were examined. What the service does well: The home was well maintained, clean and furnished to a high standard. Residents were satisfied with their accommodation. The gardens were attractive and residents and their relatives were seen in the garden. Staff were respectful towards residents and residents and relatives spoke highly of staff. The arrangements for the provision of meals was satisfactory and residents were happy with the meals provided. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Arrangements were in place to ensure that residents admitted there are appropriate and their needs assessed. Deficiencies were however, noted and improvements are needed to ensure that service users are fully assessed. EVIDENCE: The three residents who were interviewed informed the inspector that they were well cared for and their care needs had been attended to. This was reiterated by the three relatives interviewed. Comments made by residents included, “satisfied with care”, “well cared for” and “staff are respectful”. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 9 A sample of four residents’ case records which were examined contained assessments and plans of care. The inspector however, noted that assessments prepared were not sufficiently comprehensive. The lifting & handling assessment of one resident was not sufficiently informative as it did not detail the assistance required by the resident. The files of another resident who was newly admitted did not contain a lifting & handling assessment. The acting manager explained that the resident concerned was mobile. The inspector further noted that a recent audit report prepared by the company’s quality and development manager indicated that residents case records did not contain the required assessments. Requirement have been made for improvements to be made. The acting manager reassured the inspector that training in care documentation had been booked for staff. The inspector was informed by the deputy manager that the home does not provide intermediate care. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents had been treated with respect and arrangements were in place to ensure that the healthcare, personal, cultural and social needs of residents were attended to. Improvements are however, needed in care documentation and in ensuring that the care needs of residents are fully assessed and attended to. EVIDENCE: Feedback received from the four residents interviewed indicated that they were of the opinion that their healthcare needs had been attended to and they had access to healthcare services. Staff interviewed were knowledgeable regarding the care to be provided to residents. When asked about the dietary needs of a resident with diabetes, staff were aware of the special diet required. The case records examined, contained risk assessments for resident who were at risk of falls. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 11 Jugs of water had been provided in bedrooms inspected to ensure that residents had access to water whenever they wanted a drink. Following requirements made in the last inspection report, the plans of care had been made holistic and now addressed the mental, social, cultural and spiritual needs of residents. Care plans had been prepared for residents concerned. Those examined had been reviewed. The plans of care of a resident who was assessed to be at risk of pressure sores was examined. No pressure area care plan was documented. This was brought to the attention of the acting head of care and the required care plan was provided during the second visit to the home (on 21 July 2006). The inspector noted that a recent audit of care documentation in the home (July 2006, done by the Quality & Development Manager) indicated that there were important deficiencies in care documentation and arrangements for meeting the care needs of residents. It revealed that care plans were not always completed and some did not have a named nurse or key worker. This was discussed with the acting manager. A requirement is made in this report for the registered person to ensure that the above deficiencies and others identified in the report are rectified. The medication administration charts examined had been appropriately signed. The temperature of the treatment room was satisfactory and noted to be no higher than 25C. Residents interviewed stated that they had been given their medication. Residents and their relatives who were interviewed indicated that staff had treated them with respect and dignity. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life and routines of residents were well organised and met the needs of residents. This ensures that residents feel valued and are able to exercise choice and control over their lives. EVIDENCE: The home had a programme of weekly social and therapeutic activities. The programme was displayed on the ground floor. Activities provided were noted to be varied and included reminiscence sessions, music, exercise, entertainment sessions and outings. Residents interviewed were generally satisfied with the activities organised. The case records examined contained social care plans and details of activities that residents had engaged in. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 13 The kitchen and arrangements for the provision of meals were examined. These were satisfactory. The menu examined was noted to be balanced and varied. Residents interviewed said they were satisfied with the meals provided and they had a choice of main dish at meal times. The kitchen was clean and a daily record of fridge and freezer temperatures had been kept. These were satisfactory. Kitchen staff interviewed were knowledgeable regarding their responsibilities. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents (and their representatives) are listened to and protected from abuse and harm. EVIDENCE: The complaints record was examined. There was documented evidence that complaints recorded had been promptly responded to. Staff who were interviewed were found to be knowledgeable regarding adult protection procedures. The staff records examined indicated that staff had been provided with instruction and guidance in adult protection. New staff had been provided with instruction during their induction period. The three residents who were interviewed stated that they had been well treated and no complaints were received by the inspector. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean, well equipped and furnished to a high standard, therefore providing a nice environment to live in. EVIDENCE: The premises were clean and well maintained. The gardens were attractive. It had a small sensory corner. Residents were seen sitting in the garden. The communal areas were brightly decorated, well furnished and appeared cosy. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 16 The required maintenance and safety certificates were seen by the inspector. These included safety inspection certificates for the lifts, hoists, assisted baths, portable appliances and gas installations. The laundry was inspected and noted to be well equipped. Linen in bedrooms were examined and noted to be clean. Bedrooms inspected had been personalised by residents. Residents interviewed stated that they were happy with their accommodation. No offensive odours were detected. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing arrangements were satisfactory. This ensures that residents are supported by a competent and effective staff team. EVIDENCE: Residents who were interviewed indicated that staff were responsive and had treated them with respect and dignity. The duty rota was examined. It indicated that in addition to the manager, there was normally at least 9 care staff (including 2 nurses) during the morning shift, 7 care staff during the afternoon and evening shifts (including 2 nurses)and 5 care staff (including 2 nurses) on waking duty during the night shifts. No concerns regarding staffing were brought to the attention of the inspector by those interviewed. Staff who were on duty were interviewed on a range of topics associated with their work (such as health and safety, adult protection, fire procedures and the mental healthcare care of residents). They were noted to be knowledgeable regarding their roles and responsibilities. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 18 There was documented evidence that staff had been provided with essential training. This included food hygiene, first aid, care of residents with dementia and health and safety. The staff records examined indicated that the required recruitment standards and procedures (including obtaining satisfactory CRB disclosures and references) had been followed. Staff further stated that they worked as a team and had been supported by their managers. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Systems were in place to protect the interests and welfare of residents and staff. Further improvements in health and safety are needed. EVIDENCE: Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 20 No registered manager manager was in post at the time of this inspection. The inspector had however, been informed by the operations manager that a new manager had been recruited and she would be in post by the end of the month. The acting manager and acting head of care were noted to be knowledgeable regarding the management of the home. Staff, relatives and residents interviewed were of the opinion that the home was well managed. Compliments had been received and these were available for inspection. Window restrictors were in place in bedrooms inspected. The inspector however, noted that some of the rooms (including bedrooms) on the ground floor did not have restrictors. These are required for security and safety reasons and an immediate requirement was made for them to be provided. The inspector noted that there had recently been a breach of security (via an unsecured window). This was discussed with the acting manager and acting head of care. To ensure that residents and staff are protected, the registered person is required to ensure that security is improved and the security plan (provided by the acting manager) is carried out. The fire log book was examined and the staff member responsible for fire safety was interviewed. He stated that weekly fire alarm tests had been carried out. Fire alarm checks, fire drills and fire training had been documented. The fire risk assessment had not been updated. An immediate requirement is made for this to be done. A current certificate of insurance was displayed. No financial records of residents were examined. The administrator informed the inspector that the home did not have such records as no money was kept by the home on behalf of residents. Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 21 Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 22 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 23 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 Standard OP3 Regulation 13(4)(c) 14(1) 14 15 17(1) 14 15 17(1) Requirement The registered person must ensure that all residents admitted into the home have comprehensive assessments. The registered person must ensure that appropriate care plans are completed for residents identified as requiring them. The registered person must ensure that the deficiencies identified in the Care Plan Audit (dated 21 July 2006, completed by the Quality & Development Manager) are rectified. The registered person must ensure that the fire risk assessment is updated. (Immediate Requirement) The registered person must provide window restrictors for all windows. (Immediate Requirement) The registered person is required to ensure that the security of the home is improved and the security plan is implemented. Timescale for action 01/09/06 2 OP7 OP8 01/09/06 3 OP7 OP8 13/09/06 4 OP38 23(4) 20/08/06 5 OP38 13(4)(c) 28/07/06 6 OP38 13(4)(c) 13/09/06 Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hadley Lawns DS0000010449.V303092.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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