Inspection on 16/05/05 for Hadley Lawns

This inspection was carried out on 16th May 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 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 12/07/06

Hadley Lawns 07/02/06

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 Hadley Highstone Barnet, Hertfordshire EN5 4QE Lead Inspector Daniel Lim Announced 16 May 2005 @ 9:00 a.m. 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. HADLEY LAWNS Version 1.10 Page 3 SERVICE INFORMATION Name of service Hadley Lawns Address Kitts End Road, Hadley Highstone, Barnet, Hertfordshire EN5 4QE 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) 020 8449 0324 Robin Comerford for Care First Care Homes (BUPA) Sharon Hillyer N Care Home with Nursing 44 Category(ies) of OP Older People registration, with number of places HADLEY LAWNS Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 November 2004 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, manager’s 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. HADLEY LAWNS Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 16 May 2005 and took one day to complete. The inspector found that most of the National Minimum Standards had been met and the overall quality of care provided was satisfactory. During this inspection, the inspector was accompanied by the manager of the home (Mrs Sharon Hillyer). The inspector was able to interview five residents and a relative. The feedback received from them was positive and they indicated that they were satisfied with the care provided. Completed questionnaires were received from seven relatives and six residents. These indicated that the respondents were on the whole, happy with the care provided. The home’s visiting physiotherapist was also interviewed. She confirmed that the healthcare needs of her clients had been attended to. A sample of six case records was examined. These were generally well maintained. The premises, including the bedrooms, laundry, kitchen and gardens were inspected. Staff on duty were interviewed and a sample of four staff records were examined. In addition, the minutes of residents’ and staff meetings were examined. What the service does well: The home was clean and furnished to a high standard. It was well maintained and the gardens were attractive. The required records were available for inspection. These were up to date. HADLEY LAWNS Version 1.10 Page 6 Staff had been provided with essential training. This was confirmed in training records examined. Records examined, indicated that staff were closely supervised and when questioned, they were knowledgeable regarding their responsibilities. Arrangements were in place to ensure that the healthcare needs of residents are attended to. Records were kept of visits made by the GP and other healthcare professionals. Residents were satisfied with the meals provided. What has improved since the last inspection? What they could do better: The registered person must ensure that pre-admission assessments include comprehensive risk assessments. Plans of care (care plans) must be comprehensive and address the holistic needs (including mental, cultural and spiritual needs) of residents. Residents (or their representatives) must be consulted when preparing their care plans. HADLEY LAWNS Version 1.10 Page 7 The registered person must review staffing levels and the roles of care staff and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the needs of residents throughout the day and night. All staff must be provided with training in adult protection. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HADLEY LAWNS Version 1.10 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 Standards Statutory Requirements Identified During the Inspection HADLEY LAWNS Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 The manager and her staff had a good understanding of the needs of residents and were able to ensure that most of their needs are met. Improvements are however, needed in the pre-admission assessment and the care and placement of residents with dementia must be reviewed. EVIDENCE: The inspector interviewed six residents and a relative. The feedback received indicated that on the whole, the needs of residents had been met. This was also confirmed in the completed questionnaires received from residents, relatives and professionals involved in the care of residents. Six case records examined were generally well maintained and contained the required assessments and plans of care. HADLEY LAWNS Version 1.10 Page 10 The inspector observed the physical condition of residents. Residents were noted to be clean and appropriately dressed. Two contracts were examined. These were comprehensive and appropriate. The inspector noted that several of the residents had dementia. As the home is not registered for dementia, a requirement is made for the care and placement of these residents to be reviewed. Through admitting residents to the home with dementia, the registered person is operating outside of the home’s conditions of registration. This matter must be addressed by the registered person as a matter of priority. An application for variation must be submitted to the CSCI as a matter of urgency. No more residents with dementia must be admitted to the home as the service is not registered to accomodate residents within this client category. The statement of purpose was examined and found to contain items specified in schedule 1 (Regulation 4(1)(c)) The pre-admission assessment of residents was examined. These were not sufficiently informative as they did not contain comprehensive risk assessments. This is required to ensure that staff are fully informed of potential risks and a requirement is made in this report for this to be attended to. HADLEY LAWNS Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 - 10 The personal and healthcare needs of most of the residents had been met at the home. The sample of plans of care for residents which were examined were not sufficiently comprehensive and improvements are needed. EVIDENCE: The feedback received from residents and relatives indicated that residents had been treated with respect and dignity. Staff interviewed were knowledgeable regarding the care to be provided to residents. The sample of six case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were available. HADLEY LAWNS Version 1.10 Page 12 The medication administration charts examined had been appropriately signed. The temperature of the treatment room and medication fridge had been monitored daily and found to be satisfactory. Residents interviewed stated that they had been given their medication. The plans of care examined did not always address the mental, cultural and spiritual needs of residents. This is needed to ensure that the holistic needs of residents are attended to. In addition, not all the plans had been signed by either residents or their representatives. This is required as evidence that they have been consulted and agree with the plans of care. The inspector noted that several of the residents had dementia and he was unable to conclude that their care needs had been fully met due to lack of mental health care plans and documented minutes of recent reviews of care. A requirement is therefore made for the care and placement of these residents to be reviewed with professionals involved. HADLEY LAWNS Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 The daily life and routines of residents were well organised and they were able to exercise choice and control over their lives. The feedback received from residents indicated that they were generally satisfied with the activities provided and the meals served. EVIDENCE: The inspector met the home’s activities’ organiser and saw the home’s programme of weekly social and therapeutic activities. The activities provided were varied and appropriate. Residents who returned their completed questionnaires indicated that they were satisfied with the activities provided. The case records examined contained details of activities that residents had engaged in. The kitchen and arrangements for the provision of meals were examined. These were satisfactory. HADLEY LAWNS Version 1.10 Page 14 There was documented evidence that residents had been visited by their families. There was also documented evidence of consultation meetings with residents. The manager was able to provide examples of how residents could exercise choice and control in their lives (such as choice of meals, daily routine and items to have in bedrooms). Evidence that residents had been provided with choice of meals was noted in the home’s menu. The inspector also noted during the inspection that residents could remain in their bedrooms and have their meals there if they chose to. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. HADLEY LAWNS Version 1.10 Page 15 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 There was evidence that the rights of residents are protected and complaints are taken seriously. This protects residents from abuse and ensures that any complaints they have are listened to and acted upon. 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 training in adult protection. Six residents who were interviewed stated that they had been well treated. HADLEY LAWNS Version 1.10 Page 16 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) 19-26 The home was clean and maintained to a high standard, therefore providing a nice environment to live in. The facilities were adequate. EVIDENCE: The premises were inspected and found to be clean and well maintained. The maintenance person who was interviewed stated that repairs had been promptly carried out. The hot water was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive. It had a water fountain and a small sensory corner. The communal areas were brightly decorated, well furnished and appeared cosy. HADLEY LAWNS Version 1.10 Page 17 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 staff interviewed were aware of the need to wash soiled and infected laundry at a temperature of at least 68C for at least 10 minutes. Linen and clothes which had been washed were examined. These were found to be clean and neatly folded. HADLEY LAWNS Version 1.10 Page 18 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) 27-30 The recruitment process in place ensures that residents needs are met by an appropriate group of staff. Concern was however expressed by three relatives and a resident regarding staffing levels (especially at weekends) and further staff training is required in adult protection. EVIDENCE: Staff who were on duty were interviewed and noted to be generally knowledgeable regarding their roles and responsibilities. Six residents who were interviewed indicated that staff were professional in their approach and respectful towards them. Three relatives and a resident indicated that the staffing levels were inadequate (particularly at weekends). This was discussed with the manager and the staff rota and staffing arrangements were examined in detail. The manager stated that the current levels were consistent with the previously agreed staffing levels. Due to concerns expressed and as the home has residents who had dementia, the registered person is required to review staffing levels with relatives, residents and staff. This review must include the manner in which staff are HADLEY LAWNS Version 1.10 Page 19 deployed (especially at weekends) to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector. The training records examined, indicated that staff had been provided with most of the essential training required. However, further training is required for some staff in adult protection. HADLEY LAWNS Version 1.10 Page 20 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) 31-38 Systems were in place to ensure that the rights and interests of residents are safeguarded. Health and safety arrangements were satisfactory so as to ensure that residents live in a safe environment. EVIDENCE: HADLEY LAWNS Version 1.10 Page 21 When interviewed on a range of topics associated with the care of residents and staff management, the manager was found to be knowledgeable. Staff interviewed expressed confidence in their manager. The required records which were examined were well maintained and up to date. A formal system of quality assurance and monitoring had been implemented. The financial records of three residents whose money were kept by the home were examined. They were well maintained and receipts had been obtained for transactions made. The fire logbook examined indicated that fire drills and weekly checks of the fire alarm had been carried out. Fire training had been arranged for staff. When questioned, staff were knowledgeable regarding the fire procedures. There was evidence in the minutes of meetings examined to indicate that residents and their representatives had been consulted regarding the management of the home. HADLEY LAWNS Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 2 3 x 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 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 HADLEY LAWNS Version 1.10 Page 23 no 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 4, 8 Regulation 23(2)(b) Requirement The registered person must arrange for the placement and care of residents with dementia to be reviewed to ensure that service users are appropriately placed and their care needs are met at the home The registered person must ensure that pre-admission assessments include comprehensive risk assesments. The registered person must provide comprehensive care plans which address the holistic needs of service users (this must include mental, cultural and spiritual needs). The registered person must consult with residents (or their representatives) when preparing their care plans. The care plans must be signed as evidence of this. The registered person must review staffing levels and the roles of care staff at the home and undertake any actions identified out of the review so as to ensure it has sufficient staff to Version 1.10 Timescale for action 16/8/05 2. 3 14(1) 1/8/05 3. 7 15(1) 13(1) 1/8/05 4. 7 15(1) 16/8/05 5. 27 18(1)(a) 15/8/05 HADLEY LAWNS Page 24 6. 27 18(1) 7. 4 10(1), 12(1) meet the needs of residents throughout the day and night. A report of actions undertaken following this review must be forwarded to the inspector. The registered person must arrange for all staff to be provided with training in adult protection. The registered person must apply for a variation to the conditions of registration to permit the home to accommodate residents who have dementia. 15/8/05 30/8/05 8. 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. Refer to Standard Good Practice Recommendations HADLEY LAWNS Version 1.10 Page 25 Commission for Social Care Inspection North London 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. Extracts may not be used or reproduced without the express permission of CSCI HADLEY LAWNS Version 1.10 Page 26 - 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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