Inspection on 08/05/07 for Hadley Lawns

This inspection was carried out on 8th May 2007.

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 12/07/06

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 8th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hadley Lawns DS0000010449.V333458.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.V333458.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 www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Maggie Ireland Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Hadley Lawns DS0000010449.V333458.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. 12th July 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 registered manager of the home is Mrs Maggie Ireland. 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.V333458.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 8th & 10th May 2007. The inspection took a total of six hours to complete. The second visit on 10th May 2006 was made to view documents not available on the first day. The inspector found that improvements had been made in the management of the home and all previous requirements made had been complied with. During this inspection, the inspector was accompanied by the manager of the home (Mrs Maggie Ireland). The inspector was able to interview five residents. The feedback received from them indicated that they were generally satisfied with the care provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record, financial records and fire records of the home. These records were well maintained. The premises including bedrooms, bathrooms, lounges, treatment room, kitchen, garden and communal areas were inspected. These areas were clean and well maintained. Five 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. Staff on duty were noted to be knowledgeable. The minutes of staff and residents’ meeting were also examined. A record of compliments received from residents and their relatives had been kept. In addition, comments regarding the healthcare of residents were received from a healthcare professional. These were positive. What the service does well: Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 6 The home was clean and furnished to a high standard. The communal rooms were spacious and cheerfully decorated. The bedrooms appeared homely. The home had a large garden which was well maintained and attractive. Residents spoke highly of staff in the home and said they had been treated with respect and dignity. Staff had been carefully selected and had received the required training. Residents were satisfied with the meals provided and kitchen staff had a good understanding of the dietary preferences of residents. The home had arrangements for ensuring effective communication and good teamwork. The home had a compliments book and evidence of appreciation from relatives for the service provided. All requirements made in the last inspection report had been complied with. What has improved since the last inspection? What they could do better: Improvements are required in the following areas. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 7 The registered person must review staffing levels with staff and residents to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector. Staff must be provided with a period of induction. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 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. Satisfactory arrangements were in place to ensure that residents’ aspirations and needs are assessed. This ensures that their needs can be identified and met at the home EVIDENCE: The five 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 by them included, “staff are polite and respectful,” “well cared for” and “satisfied with care provided”. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 10 Compliments and thank you letters received from relatives kept in a book and made available for inspection. A sample of four residents’ case records which were examined, contained comprehensive assessments (including pre-admission assessments). Risk assessments together with strategies for minimising risks had been prepared. Residents in the home were noted to be clean, appropriately dressed and appeared well cared for. The manager stated that the home does not provide intermediate care. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 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 health and personal care were found to be satisfactory. This ensures that residents’ healthcare, personal, cultural and social needs are attended to. Residents were satisfied with the arrangements. EVIDENCE: The five residents interviewed, indicated that their healthcare needs had been met. Comments made included, “I have been seen by the doctor”, “my medication has been given to me” and “ happy with the care here”. The sample of four case records examined were up to date and plans of care had been reviewed monthly. Records of healthcare appointments and Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 12 treatment were documented. A record of GP visits and medication reviewed had been maintained. The arrangements for the administration of medication were satisfactory. A record of the temperature of fridge and treatment room had been maintained. Medication administration charts (MAR charts) had been appropriately signed. Residents were able to confirm that they had been given their medication. The records of a resident with diabetes indicated that her condition was closely monitored and she had been given the prescribed medication. The records of a resident with a pressure sore contained a pressure area care plan. Monitoring charts had been provided and the tissue viability nurse had been consulted regarding pressure area care. In addition, comments regarding the healthcare of residents were received from a healthcare professional. These were positive. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 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 the daily life and routines of residents were found to be satisfactory. This ensures that residents have access to a range of activities and their dietary, cultural and social preferences are met. Residents were on the whole happy with their daily routine and the activities available. EVIDENCE: Residents interviewed were of the opinion that the home had sufficient activities and these activities were appropriate. The daily activities programme was on display near the reception area. Activities provided included exercise sessions, gardening, aromatherapy, art and crafts, games and outings. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 14 Residents who were interviewed stated that they had been visited by their relatives. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen was clean and well equipped. Residents interviewed indicated that they were generally satisfied with the meals provided. The menu reflected the cultural and religious preferences of residents. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 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. 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 are well treated and protected from abuse. Residents stated that they had been well treated by staff. EVIDENCE: The complaints record was examined. Complaints recorded had been promptly responded to. The manager and her staff when interviewed, were aware of the procedure to follow when responding to allegations of abuse. There was documented evidence that staff had been provided with adult protection training. Residents who were interviewed indicated that they had been well treated by staff. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 16 The issue of equalities and diversity was discussed with the manager and her staff. Staff indicated that they had been instructed to treat all residents sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. The home had an equalities and diversity policy and procedure. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 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 well equipped, clean and furnished to a high standard, therefore providing a pleasant environment to live in. Residents were pleased with their accommodation. EVIDENCE: Residents interviewed stated that they were happy with the accommodation provided. The premises were inspected and found to be clean and cheerfully furnished. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 18 All bedrooms have ensuite facilities and were well equipped. The laundry was inspected and arrangements for the laundering of soiled linen were found to be satisfactory. The home was maintained to a high standard. Safety inspections had been carried out on the portable appliances, gas installations and electrical installations. The gardens were attractive, colourful and seating had been provided. A centre feature was the sensory corner with herbs and aromatic plants. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 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. The staffing arrangements were on the whole, satisfactory. Staff were carefully recruited and had received the required training. This ensures that residents can be provided with the care they need. Further improvements are however, required in the staffing levels and the induction of staff. EVIDENCE: Residents who were interviewed indicated that they had been treated with respect and dignity. The staff rota was examined. This indicated that in addition to the manager and her deputy (head of care) there was a minimum of - 9 staff on duty during the morning shifts (7 carers & 2 nurses) - 7 staff on the afternoon and early evening shifts (5 carers & 2 nurses) - 5 staff on the night shifts (4 carers & 1 nurse) Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 20 Staff were of the opinion that the staffing levels were inadequate and an extra carer is needed in the mornings and afternoons. They explained that residents in the home needed more assistance as they had become more frail. They further stated that the lack of staff had caused stress amongst them. Two residents indicated that there were occasions when staff did not respond promptly. They were of the opinion that this was because staff were too busy. The findings were discussed with the manager who agreed to carry out a review of staffing. The three new staff records examined contained the required documentation such as two references, satisfactory CRB disclosures, contracts and evidence of identity. Induction records were not available for a staff member. This is required to ensure that staff have been provided with a period of induction. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 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 run in the best interest of residents and satisfactory arrangements were in place to ensure the safety and welfare of residents and staff. EVIDENCE: Residents interviewed were of the opinion that the home was well managed and their care needs had been met. Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 22 The manager is a qualified nurse and she stated that she had management qualifications. The inspector was provided with evidence that residents and their representatives had been consulted as part of the home’s quality assurance monitoring. The minutes of these meetings were available for inspection. The home had a valid certificate of insurance. Staff interviewed informed the inspector that they had been provided with regular supervision sessions. Documented evidence was available for inspection. The minutes of staff meetings were also available for inspection. The fire records examined contained details of regular fire drills, fire training and weekly fire alarm checks carried out. Fire exits were kept clear. The home had an updated fire risk assessment. A recent consumer survey report of the services provided by the home was available for examination. This was positive and the satisfaction level was better than in the previous year. . Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 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 X X N/a 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 2 17 X 18 3 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 3 X 3 X 3 3 X 3 Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18(1)(a) Requirement The registered person must review the staffing levels and the roles of staff with staff and residents to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector. 2. OP31 9(2)(b)(i) The registered manager must ensure that staff are provided with a period of induction. 01/08/07 Timescale for action 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 25 Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hadley Lawns DS0000010449.V333458.R01.S.doc Version 5.2 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. 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