Inspection on 08/11/05 for Hafod Nursing Home

This inspection was carried out on 8th November 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 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 27/07/05

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 Announced Inspection 8th November 2005 09:45 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 Hafod Nursing Home DS0000024844.V252389.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. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hafod Nursing Home Address 9 - 11 Anchorage Road Sutton Coldfield West Midlands B74 2PJ 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) 0121 354 9442 0121 354 2616 Hafod Care Homes Ms Mahnaz (Nazy) Mohtadi Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Terminally ill over 65 years of age (29) of places Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Mahnaz (Nazy) Mohtadi undertakes and obtains successfully the Registered Managers Award or equivalent by December 2005. 27/07/05 Date of last inspection Brief Description of the Service: Hafod Nursing Home is comprised of two converted houses situated within a residential area close to Sutton Coldfield town centre. The home has good access to bus and rail links and is within 5-10 minutes walking distance of the town centre. The linked two storey Victorian style houses have been adapted for its current purpose. The premises comprise of a main lounge, two conservatories, a main dining room and a further lounge with integral dining area. All communal areas are located on the ground floor. There is a mixture of single and shared bedrooms situated on both floors. The upper floor is accessible via a shaft lift. The home has a large well established and maintained garden at the rear of the building, which residents can frequent during clement weather. There is sufficient off road parking at the front of the premises to accommodate six vehicles. The home provides nursing care for up 29 persons who are aged 65 years or above. Four beds are contracted for the provision of intermediate care. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an announced inspection, which focussed upon the requirements generated from the last inspection and the key standards that had not been assessed within the year. The outcome was determined by a variety of means. In depth discussions were held with the registered manager and a brief talk held with the registered provider and two members of staff were interviewed. Five residents, one relative and a health professional were independently spoken with. Relevant documentation was examined including four care plans, one of which was case tracked in order to ensure that all the identified needs were being met. The system for staff recruitment and training were reviewed and a tour of the premises carried out. At the conclusion verbal and written feedback was given to the registered manager and trained staff. What the service does well: What has improved since the last inspection? New dining room furniture has been purchased. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 6 Some bedrooms have been redecorated and carpeted. The carpet in the main lounge has been replaced. The smaller lounge has been redecorated. A new medicines trolley has been acquired to provide safe storage of medications for the west wing. The central heating has been up graded and two new boilers installed. The recent five year hard wiring test included up grading of electrical devises and emergency lighting. All but one of the requirements generated from the last inspection had been fully addressed. 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 DS0000024844.V252389.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 the following standard(s): 1 and 3 Prospective residents are supplied with written details to assist them in making an informed choice about the home. The pre-admission assessment is now maintained within the care plan and used as a tool for a full assessment of needs upon admission. EVIDENCE: The statement of purpose had been slightly amended and now provides all required information about the home and accurately reflects the category of registration. The pre-admission assessment is used as the framework for the more detailed assessment that is carried out on admission of a new resident. Standards 2 and 6 were examined at the last inspection and were fully met, standard 4 was exceeded. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 9 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 and 10 Care plans identify resident’s needs and how these should be addressed and files provided clear evidence of the involvement of external professionals. The process adopted for the administration of medications ensures the safety of residents. Personal support is provided in such a way as to promote privacy and dignity of residents. EVIDENCE: Resident’s files have been improved and include comprehensive physical and mental health needs and how the care should be delivered. The risk assessments are considered to be somewhat lacking in detail. The organisation is currently reviewing the tool and plans to introduce a comprehensive means of risk assessing. There was written evidence that the advice provided by external professionals is respected and acted upon. Documentation regarding pressure sores was found to be comprehensive. Regular reviews of care plans were being carried out. At the last inspection the system for the administration of medications was found to be satisfactory. This inspection was no exception and the home Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 10 confirmed that it has recently confirmed a contract for the disposal of unused medications. Observations during the visit indicated that resident’s personal care is delivered in the privacy of a bathroom or their own bedroom. Feedback received from residents and a relative was positive. One resident said, “ This is a first class home”, another reported, “The home is very good, I like it”. If a resident’s health significantly deteriorates he/she is given a choice regarding remaining at the home or being admitted to hospital. Confirmation of the decision is following consultation with relatives, the GP and other health care professionals who are involved with the care. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 11 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 and 14 Although the home provides in-house and external activities it needs to be formalised with the development of a programme. There is documentary evidence that residents influence the day to day operations of the home. EVIDENCE: The registered manager advised that the activities organiser had recently left the home but that many staff through the appraisal process had indicated an interest in participating and had made suggestions for various recreational pursuits. Plans were in place to introduce a fish and chip supper with a video. A varied range of activities was being provided, which included external entertainers and exercises to music. Religious services are provided by two denominations. Several residents go out to attend church services. Relatives occasionally take residents out and they are invited into the home at weekends to have a meal. It was reported that the current client group show little interest in outings. The registered manager was advised to monitor the situation regarding outings and to develop a programme to enable residents to have prior knowledge of the activities. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 12 The home holds regular residents meetings; minutes are produced and circulated accordingly. Permanent agenda items include, the food menu, entertainment and suggestions for improvements. The home adopts a policy of open visiting. A resident said, “My daughter visits anytime and is always offered a cup of coffee”. A relative spoken with also provided positive feedback. Standard 15 was examined at the last inspection and was fully met. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 the following standard(s): 16 Comments and complaints from residents and relatives are listened to and acted on. EVIDENCE: The written complaints procedure has been further developed and was determined to be satisfactory. The home has also improved on the system of logging; investigating and monitoring of outcomes in order to ensure positive and timely responses are made. The registered manager reported that the home has not received any formal complaints since the last inspection. Standard 18 was examined at the last inspection and was fully met. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 24, 25 and 26 Accommodation is comfortable and well maintained within a safe and homely environment. Facilities provided are adequate to meet the needs of the current client group. EVIDENCE: There is a welcoming and relaxed atmosphere throughout the home. The home offers a choice of main lounge or smaller lounge and dining venue. The home is furnished to a good standard and there is a programme of maintenance and repairs. The smaller integral lounge/ dining area/ kitchenette permits residents and visitors to make refreshments. There are an adequate supply of communal toilets and assisted bathing situated strategically on each floor. Plans have been formalised to extend the premises, this will result in an increased number of bedrooms, upgrading of some rooms, extra communal space and improved laundry facilities. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 15 Bedroom accommodation is a mixture of single and shared rooms, which vary in size and layout. The rooms visited appeared comfortable and well personalised. Some rooms did not contain all of the required furniture as per standard 24.2. The registered manager was advised to document and regularly review resident’s preferences regarding the reduced amount of furniture in these rooms. The home was warm, airy and lighting is domestic in design. Regular random water temperature checks are carried out and documented of any hot water outlets that residents come into contact with. Odour control was well managed and the home was generally tidy and hygienic. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 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 and 30 Although staffing levels were adequate to ensure acceptable levels of care the home must comply with Working Time Regulations 1998. Sufficient staff training has been delivered to enable staff to have the knowledge and skills to fulfil their roles. EVIDENCE: The duty rota indicated that adequate trained and care staff are deployed for the current client group. The duty rota must clearly indicate the number of hours worked by each individual. It was noted that some staff work an excessive number of hours; this issue needs to be addressed. The home has a full team of ancillary staff including a maintenance operative who also works at the sister home. At least 50 of care staff have been successfully trained to NVQ level 2 or above. The rolling programme of training ensures that staff receive all mandatory training and other courses that are deemed necessary to meet the needs of the current residents. Examination of staff files indicated that the home carries out all of the relevant checks before a post is offered to the respective applicant. Appropriate induction programmes are utilised for new recruits. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 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, 35, 36 and 38 The registered manager is well supported by her senior staff in providing clear leadership with staff demonstrating their roles and responsibilities. The system for the safe keeping of resident’s personal monies fails to provide adequate protection. The health and safety arrangements serve to minimise any risks to residents and staff. EVIDENCE: The registered manager has a wealth of experience within the care sector and is supported by a senior sister for two days each week. She is currently undertaking training to achieve the registered managers award. Observation revealed that the registered manager leads by example. Staff reported that that in their opinion the home is well managed and all senior staff are approachable and open to suggestions. The system in place for the recording of financial transactions on behalf of resident’s personal monies was not robust and must be improved. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 18 All care staff have regular formal supervisory meetings and an annual appraisal. The tool used for these processes were found to be satisfactory. All relevant testing and servicing of equipment has been carried out including weekly fire alarm checks, regular fire drills and monthly emergency lighting. The documentation was found to be up to date for all aspects of health and safety. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 3 3 X X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 2 3 X 3 Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 20 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 OP12 Regulation 16(2)m Requirement The registered manager must provide residents with prior notice of recreational activities by developing and displaying a programme. The registered manager must ensure that the hours worked are clearly displayed on the duty rota and adhere to Working Time Regulations 1998. The registered manager must successfully complete the registered managers award. The registered manager must develop a comprehensive recording system in respect of personal monies held on behalf of residents. Timescale for action 31/12/05 2. OP27 18(1)a 31/12/05 3. 4. OP31 OP35 9(2)bi 13(6) 31/01/06 15/12/05 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 Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 21 1. 2. 3. OP7 OP12 OP24 The home is recommended to complete the work regarding the implementation of an improved risk assessment tool. The registered person should consider provision of an improved quality of the television viewing for those residents who are visually impaired. Resident’s preferences regarding bedroom furniture should be recorded within the respective care plan and regularly reviewed. Hafod Nursing Home DS0000024844.V252389.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham 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 DS0000024844.V252389.R01.S.doc Version 5.0 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. 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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