This inspection was carried out on 4th February 2010.
CQC found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Hafod Nursing Home 9-11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Donna Ahern Date: 0 4 0 2 2 0 1 0 Information about the care home
Name of care home: Address: Hafod Nursing Home 9-11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ 01213549442 01213542616 hafodltd@aol.com None Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Hafod Care Organisation Limited care home 29 Number of places (if applicable): Under 65 Over 65 29 29 old age, not falling within any other category terminally ill Conditions of registration: 0 0 That Mahnaz (Nazy) Mohtadi undertakes and obtains successfully the Registered Managers Award or equivalent by December 2005. Date of last inspection Brief description of the care home Hafod Nursing Home provides general nursing care for up to 29 people. The Home is not registered to provide care for people who suffer with dementia. Four rooms are contracted by the Primary Care Trust for the provision of interim care. The Home comprises of two converted houses within a residential area that have been adapted for its current use and is located close to Sutton Coldfield town centre. There is good access to local bus and rail links and it is within 5 -10 minutes walking distance of the town centre. There is off road parking at the front of the building for six cars. There is a choice of seating and dining areas located on the ground floor. There is a mixture of
Care Homes for Older People Page 2 of 9 Brief description of the care home single and shared rooms located on both floors and with the exception of one bedroom, all have en suite. There is a passenger lift for people to access both floors and a large well-established secure garden situated to the rear of the premises, which is suitable for wheelchair users. There is a no smoking policy within the home however smoking is permitted within the garden area. There is a notice board on entering the home, which displays a range of information for people living in the home and their visitors. A service user guide was available but this did not include information about the current fee rates. This information can be requested from the home. Additional costs include dry cleaning, hairdressing, chiropody and newspapers. A copy of the previous inspection report was available in the reception area of the Home for anyone interested to refer to. Care Homes for Older People Page 3 of 9 What we found:
The focus of this inspection undertaken by the Care Quality Commission (CQC) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. The last key inspection of this service was completed on the 27th October 2009. This random visit was undertaken by two inspectors over one day. There were 23 people living at the home and the home did not know that we would be visiting. The reason for this visit was to review the homes progress in meeting the requirements made at the last key inspection. During this visit we looked at peoples care records, medication management, staffing levels and risk assessments to do with heating safety. We looked at two peoples care plan in detail. We spoke with two registered nurses, three care staff, the manager, owner principle manager and five people who live at the home. We spent some time in communal areas observing care practices and staff interactions. We looked at the file for a person who had recently moved into the home. They had transfered from the owners residential care home located a short distance away. We saw that the new care plan format had been used. Information was well laid out and easy to find. However, a pre assessment had not been completed. An assessment was completed by the manager on the day of the transfer. When we read the daily records and monitoring charts we were concerned about the persons poor food and fluid intake. There was no specific care plan for nutrition on the file we were given and no detail about food preferences.The person hadnt been weighed on admission and the MUST (Malnutrition universal screening tool) hadnt been completed although the care plan states it should be completed within 24 hours of admission. When we spoke to the manager and owner they were able to tell us a lot more information about the persons wellbeing and healthcare interventions that were taking place. They told us they were still in the process of completing the care plan. They provided us with a nutritional care plan which had been completed in the previous home they said they were still working to this. However this information took a long time to find so it was not readily accessible for staff to refer to. It had not been reviewed on the persons transfer to the nursing home and did not reflect the significant lack of food and fluid intake that we established from reading records and talking to staff. We could not see any evidence from the food records that the person was offered any food after 17:00 each day despite on some days refusing lunch and tea. Four of the five staff we spoke to had not seen the persons file. Three of the staff could tell us that there was concern about the persons food and fluid intake and one person knew about the further medical interventions taking place. The manager told us in the response to the draft report that each member of staff had been given a written handover sheet and she feels this is excellent practice and keeps staff informed. The home has not met a previous requirement about having care plans in place for specific health care needs.We have referred our concerns on to CQC regional enforcement team so they can advise us on what further action needs to be taken. At the time of finalising this report we can confirm that an enforcement notice will not be served. We looked at the care plan for a person who had been living in the home for a while. The
Care Homes for Older People Page 4 of 9 layout of the care plan is in the old format so information is not as easy to find. The care plan was due for review so that staff have the information they need to meet peoples current needs. We saw that the turn charts in place to ensure the person was being monitored and their position changed to prevent sore skin had been completed as required. We looked at the arrangements in place for medication practice and administration for two people. We saw that medication administration records (MAR) had been signed when medication was administered. The medication we audited was correct. There have been a lot of staff changes. Some of these have been due to disciplinary action by the home in response to poor practice. This should ensure that people are protected from unsuitable staff working there. We looked at the staff rota to establish that adequate staffing levels and experienced staff were on duty to meet people needs. Two registered nurses were on duty and four care staff. One of the registered nurses was on induction and one had worked in the home for four weeks. We were concerned about some staffing matters including, staffs lack of knowledge of how many people were being cared for in the home, a delay in the staff handover taking place, a registered nurse on induction dealing with medication queries, staff not reading peoples care plans and the rota not accurately reflecting who is working in the home on the day of the visit. We were not assured that staffing skills and numbers fully ensure the wellbeing of people. We saw that a risk assessment had been completed for radiators and a number had protective covers fitted. The use of free standing heaters had been assessed for their safety so people are not at risk of injury. What the care home does well: What they could do better:
This is a random inspection and therefore not all the core standards were assessed. Care plans must be in place for specific healthcare needs so staff know how to assist people. Assessments must be completed prior to admission so that the home knows if they can
Care Homes for Older People Page 5 of 9 meet the persons needs and how these needs will be met. There must be enough staff on duty who have the skills and knowledge to meet peoples needs. Rotas should be accurate so ensuring that staff with the right skills and in the right numbers are on duty to meet peoples needs. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 7 12 (1) a Care plans should be in place 11/12/2009 for specific health care needs so it is clear what action staff should take and should detail when further intervention maybe required. Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 3 14 Pre assessments must be completed prior to admission. So the home and prospective people can be sure their needs can be met. 11/03/2010 2 27 18 There must be adequate 11/03/2010 numbers of staff with the right skills mix on duty at all times. So peoples needs are met. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 27 The rota should accurately reflect who is working in the home so an assessment of staff skills and numbers can be made ensuring peoples needs can be met. Care Homes for Older People Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 9 of 9 - 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!
