Inspection on 07/02/06 for Hadley Lawns

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hadley Lawns 08/05/07

Hadley Lawns 12/07/06

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 Unannounced Inspection 7th February 2006 01:30 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 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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.V269782.R01.S.doc Version 5.0 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.com Care First Care Homes Limited (BUPA Care Services) Sharon Hillyer Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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. 16th May 2005 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. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 7 February 2006 and took three hours to complete. The inspector found that most of the National Minimum Standards assessed had been met and the overall quality of care provided was of a high quality. During this inspection, the inspector was accompanied by the manager of the home (Mrs Sharon Hillyer). The inspector was able to interview four residents. The feedback received from them was positive and they indicated that they were satisfied with the care provided. A sample of four case records was examined. These were well maintained. The premises, including the bedrooms, laundry, treatment room, kitchen and gardens were inspected. Four staff on duty were interviewed and a sample of three 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. Repairs identified had been carried out promptly. The required records were available for inspection. These were up to date. Staff had been provided with essential training. This was confirmed in training records examined. Staff were knowledgeable regarding their roles and responsibilities. Records were kept of visits made by the GP and other healthcare professionals. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 6 Residents were happy with the meals provided. 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 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 the following standard(s): 3, 4 The manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs are met. EVIDENCE: Four residents who were interviewed indicated that their care needs had been met at the home and they were happy with the care provided. Comments made included, “good staff”, “well cared for”, “satisfied with care”. A sample of four residents’ case records which were examined, contained assessments, plans of care and details of how residents needs had been met. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. Following requirements made in the last inspection report, the registered person had applied for and was granted a variation to the registration to permit it to accommodate a number of named residents with dementia. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 Arrangements were in place to ensure that the personal and healthcare needs of residents are met at the home. The sample of plans of care for residents which were examined were not sufficiently comprehensive and improvements are needed. EVIDENCE: Feedback received from the four residents interviewed 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 four case records examined were up to date and plans of care had been reviewed. The case records contained details of medical and healthcare treatment provided. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 11 The plans of care however, 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 medication administration charts examined had been appropriately signed. The temperature of the treatment room was satisfactory and noted to be no higher than 25C. An electric fan was in place. Residents interviewed stated that they had been given their medication. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 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 home had a programme of weekly social and therapeutic activities. The activities provided were noted to be varied and appropriate. These included reminiscence sessions, music, exercise, entertainment sessions and outings 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. Residents interviewed said they were satisfied with the meals provided. The chef interviewed was knowledgeable regarding her responsibilities. Evidence that residents had been provided with choice of meals was noted in the home’s menu and confirmed by the chef. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 13 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 There was evidence that the residents were listened to and protected from abuse and neglect. 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. The four residents who were interviewed stated that they had been treated with respect. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 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 home was clean and maintained to a high standard, therefore providing a nice environment to live in. The facilities were adequate. EVIDENCE: Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 16 The premises were clean and well maintained. The gardens were attractive. It had a small sensory corner. The communal areas were brightly decorated, well furnished and appeared cosy. The required maintenance and safety certificates were seen by the inspector during the last unannounced inspection. These included safety inspection certificates for the, lifts, hoists, assisted baths, portable appliances and gas installations. The assisted bath and hoists had been inspected since the last inspection. The laundry was inspected and staff interviewed were aware of the need to wash soiled and infected laundry in a special sluice cycle. Linen and clothes which had been washed were examined. These were found to be clean and neatly folded. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 17 A random sample of fixtures and wall plugs in the home were checked. These were noted to be secure. The maintenance man however, informed the inspector that some of the fixture had recently been insecure. This was reported to him by care staff. In response to this, he had checked and secured fixtures which were loose. Documented evidence of this was provided by him. He further reassured the inspector that he will continue to check all fixtures and secure any which are loose. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 18 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 19 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 Staff were capable and knowledgeable regarding their roles and responsibilities thus ensuring that residents are supported by a competent and effective staff team. EVIDENCE: Staff who were on duty were interviewed and noted to be knowledgeable regarding their roles and responsibilities. The four residents who were interviewed indicated that staff were pleasant and respectful towards them. The training records examined, indicated that staff had been provided with essential training. This included training in adult protection, infection control, lifting and handling and fire safety. The staff rota was examined and staffing arrangements examined in detail. No concerns regarding staffing were brought to the attention of the inspector by those interviewed. The sample of staff records examined indicated that the required recruitment procedures had been followed. Two references and CRB disclosures had been obtained for staff recruited. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 20 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 21 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, 32, 33, 35, 36, 38 The home was well managed and systems were in place to ensure the welfare of residents and staff. Improvement is however needed to ensure that staff are aware of the procedure to follow after an accident. EVIDENCE: When interviewed, the manager was found to be knowledgeable and residents were of the opinion that the home was well managed. There was evidence that staff and residents were consulted regarding the management of the home. Residents were able to confirm that their preferences regarding holidays, outings and meals provided were responded to. All four residents expressed satisfaction at the way the home was managed. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 22 Staff interviewed indicated that they were happy with the management of the home. They were of the opinion that the manager was fair and approachable. Weekly fire alarm checks, fire drills and fire training had been documented. The emergency lighting had been checked regularly. The accident records were examined. The inspector noted that the GP was not informed following a fall sustained by a resident. There was no record which indicated that the responsible doctor was called or medical assistance sought immediately after the fall. This is required to ensure that the resident receives appropriate care or treatment (if required). A requirement is made accordingly. Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 23 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 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 4 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 3 3 3 3 3 X 2 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 15(1) 13(1) Requirement The registered person must provide comprehensive care plans which address the holistic needs of service users (this must include mental, cultural and spiritual needs). This requirement is restated 2. OP7 15(1) 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. This requirement is restated 3. OP38 12(1) 13(1)(4) The registered person must ensure that the responsible doctor is informed immediately / or medical advice sought, after a service user(s) has had a fall. 20/03/06 30/04/06 Timescale for action 01/04/06 Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 25 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.V269782.R01.S.doc Version 5.0 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Hadley Lawns DS0000010449.V269782.R01.S.doc Version 5.0 Page 27 - 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!