Inspection on 27/07/05 for Hafod Nursing Home

This inspection was carried out on 27th July 2005.

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

Other inspections for this house

Hafod Nursing Home 04/02/10

Hafod Nursing Home 27/10/09

Hafod Nursing Home 18/12/08

Hafod Nursing Home 02/07/08

Hafod Nursing Home 07/08/07

Hafod Nursing Home 18/10/06

Hafod Nursing Home 08/11/05

Hafod Nursing Home 18/10/04

Hafod Nursing Home 23/06/04

Hafod Nursing Home 09/02/04

Hafod Nursing Home 18/09/03

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

CARE HOMES FOR OLDER PEOPLE Hafod Nursing Home 9-11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ Lead Inspector Kath Strong Unannounced 27 July 2005 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. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hafod Nursing Home Address 9-11 Anchorage Road Sutton Coldfield West Midlands B76 2PJ 0121 354 9442 0121 354 2616 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) Hafod Care Homes Ms Mahnaz Care Home 29 Category(ies) of Old People registration, with number of places Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2004 Brief Description of the Service: Hafod Nursing Home comprises of two converted houses within a residential area, located close to Sutton Coldfield town centre. The home has good access to local bus and rail links and is within 5-10 minutes walking distance of town centre. The two two storey Victorian style houses have been adapted for its current purpose. The premises comprise of two lounges, two conservatories one main separate dining room and a further integral dining area. All communal rooms are situated on the ground floor. There are a mixture of single and shared rooms located on both floors. There is a shaft lift for residents to access both floor. There is a large well established garden situated to the rear of premises. There is sufficient off road parking at the front of premises to accommodte six vehicles. The home provides nursing care for up to 29 persons who are aged 65 years of above. Four of beds are contracted for the provision of intermediate care. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to carry out an unannounced inspection, the outcome of which was determined by a variety of methods. In depth discussions were held the registered manager who also provided assistance. Relevant documentation was examined and four care plans reviewed two of which included case tracking in order to ensure that all identified care needs were being met. Conversations were held indecently with five residents and one trained member of staff. A tour of the premises was carried out. At the conclusion verbal and written feedback was provided to the registered manager. What the service does well: What has improved since the last inspection? The home has a contract to conduct the practical training of adaptation nurses; this serves to facilitate staffing levels and recruitment means of trained staff. New armchairs and tables have been purchased. The resuscitation equipment and nebulisers have been replaced. A second medicines trolley has been ordered to accommodate the large supplies. A new microwave, dishwasher, water boiler and milk dispenser have been supplied to the kitchen. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 6 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. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 6 Prospective residents are supplied with the majority of information to assist them in making an informed decision about the home. A comprehensive preadmission assessment is carried out but the document is not maintained within the home. The home has a contract for the delivery of intermediate care. EVIDENCE: The statement of purpose was examined an was found to be in need of slight amendment in respect of complaints and must contain details of the registered manager. The service user guide was determined to be satisfactory; a copy of the service user guide is issued to each resident. All persons residing within the home irrespective of funding arrangements are issued with a contract of terms of residency. The pre-admission tool used by the home also includes funding arrangements and is forwarded to the organisations head office. The pre-admission tool in respect of all care and recreational needs must be retained and utilised as the framework for the detailed assessment upon admission. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 9 Evidence was provided that the staff regularly reviews resident’s needs and where it is identified that the needs can no longer be met alternative accommodation will be sought. The contract of intermediate care beds has been reduced from ten to four. This action is due to the categories the home was expected to provide services for that did not reflect the terms of the contract. The permanent residents now also frequent the dedicated day unit for the intermediate beds. There appeared to be good relationships between residents and a member of staff is allocated to the area to ensure that resident’s needs are met and monitored. There is a high level of input of external professionals for those persons receiving intermediate care. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Care plans failed to provide detailed information in respect of personal care and social history. External professionals are consulted. The systems in place for administration of medications are satisfactory. Personal support is offered in such a way as to promote and respect privacy and dignity. EVIDENCE: Resident’s files need to include more details in respect of mental health and guidance to staff in instances when inappropriate behaviour is displayed. The staff must ensure that the rationale and risk assessments conducted for the use of bedsides be taken fully into consideration before decisions are made. Although files were being reviewed monthly there was no evidence that six monthly formal reviews are being carried out. Files need to include details of resident’s family histories, life backgrounds and social preferences, the details of which may influence behaviour patterns displayed in later life. The staff adopts a proactive approach to the input of external professionals. The system for the safe administration of medications appeared to be robust. The senior nurse was currently establishing a contract in order to comply with the new methods of disposal of medications. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 11 Observations during the visit and discussions held with residents indicated that there are no concerns in respect of maintaining their dignity and respect. One resident commented, “staff are exceptionally good”, another said, “at night staff are very good at responding to the nurse call bell”. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 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 standard(s) 15 The meals in the home are good offering both choice and variety with special diets being catered for but grave concerns were expressed regarding the unacceptable workload placed upon kitchen staff. EVIDENCE: The menu offer a good range of choice for all meals and residents are consulted about the planned reviews of menus. Residents reported, “there is plenty of choice”, “I can request snacks at any time”. The home provides all cooked meals for the nearby residential home and cooked lunches for a number of domiciliary care clients. One cook and a kitchen assistant are insufficient to carry out the extra tasks. The organisation must address this as a matter of urgency. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 13 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 and 18 The complaints are not dealt with comprehensively in respect of information provided and monitoring of outcomes. Arrangements for protecting residents are satisfactory. EVIDENCE: The written complaints procedure required further development to include timescales for resolution and amendment in respect of the complainants right to contact CSCI at any stage of the complaint. The system in place for dealing with complaints should include a means of monitoring of the outcomes. The documentation in place indicated that the staff comply with the Birmingham multi-agency guidelines in cases of abuse or suspected abuse. Staff receive in-house training, the registered manager needs to ensure that this is sufficient to provide staff with an acceptable level of knowledge. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 14 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, 20, 21, 22, 24 and 26 Residents live in a comfortable and homely environment. Hygiene levels generally were good but the lounge carpet was not acceptable. EVIDENCE: There was a welcoming and relaxed atmosphere within the home. There is a programme of maintenance and re-decoration in place. Communal facilities include a main lounge, a separate dining room, a conservatory and the integral day care unit, which incorporates a lounge/dining area and kitchenette for use by residents. There is also an extensive enclosed rear garden. The carpet within the main lounge was noted to have a mal odour and there was a threadbare section at the rear of the lounge, which poses a health and safety risk to residents frequenting the rear doorway. The registered manager advised that cleaning had failed to remove the mal odour. The carpet needs to be replaced. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 15 There was an adequate supply of communal toilets and bathing facilities situated strategically throughout the home. Plans have been formalised to extend the premises, this will result in an increased number of bedrooms, extra communal space and improved laundry facilities. Bedroom accommodation is a mixture of single and shared rooms, which offered rooms of varying layout and design. The rooms visited appeared to provide comfortable and homely accommodation. They were personalised to the degree of preference of the occupant. With the exception of the lounge carpet the home was found to be tidy, clean and odour control was being well managed. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 16 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 The morale of care staff is high resulting in an enthusiastic workforce that works positively to improve the quality of life of residents but staffing of the kitchen is grossly inadequate. EVIDENCE: The home was almost fully staffed and enjoys a low staff turnover resulting continuity of care. There has been a vacancy for a deputy manager for some time and consideration was being given on how to resolve the issue. The registered manager is considering delegation of tasks to senior staff in order to ensure full day-to-day operation of the home is carried out effectively. The issue discussed regarding allocated staff for the kitchen must be addressed. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 17 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, 32, 33 and 36 The manager has a clear vision and development plan for the home, which has been communicated to residents and staff. There is failure of appropriate staff supervision to ensure that the health, and welfare of residents are being fully met. There is continuation of the organisations failure to comply with Regulation 26 in ensuring that the interests of the residents are fully addressed. EVIDENCE: The registered manager has a wealth of experience and is currently undertaking the registered managers award. She runs the home in an open and transparent manner and was observed to have good relationships with residents and staff. The registered manager is advised to consider the implications of not employing a deputy and the resultant workload from an extension to the premises. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 18 The registered provider must carry out monthly unannounced inspections and forward reports to CSCI. This has not been actioned from the previous inspection. Formal staff supervisions are not being carried out, this issue must be addressed. Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 4 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 x 3 x 2 STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 3 2 x x 1 x x Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 20 Yes 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. 2. Standard OP1 OP3 Regulation 4(1) 14(1) Requirement The registetered person must amend and further develop the statement of purpose. The pre-admission assessments must include all items listed in 3.3 of this standard and be maintained within the respective residents care plan. The registered person must ensure that care plans are comprehensive, that a full rationale is in place when decisions are made and that formal reviews are carried out. The complaints procedure must be amended and further devloped. The registered person must forward an application for variation for proposed extension to the home. The registered person must replace the lounge carpet. Timescale for action 30th September 2005 30th September 2005 15th October 2005 3. OP7 15(1 & 2)c 4. 5. OP16 OP23 22(1 & 2) 39h Prior to comm of works. 15th October 2005 6. 7. 8. OP20, 26 & 38 OP31 OP33 23(2)b d 9(2)b i 26 15th October 2005 The registered manager must 31st successfully complete the October registered managers award. 2005 The registered provider must 30th carry out monthly unannounced September inspections and forward copies of 2005 the reports to CSCI. Version 1.40 Page 21 Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc 9. OP36 18(2) N.B. This requirement remains outstanding from previous inspections. All staff must receive formal supervision at least six times per year and records of such meetings maintained. 15th October 2005 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 Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Hafod Nursing Home E54 S24844 Hafod NH V241875 270705 Stage 4.doc Version 1.40 Page 23 - 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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