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Inspection on 23/01/06 for Hafod Residential Home

Also see our care home review for Hafod Residential Home for more information

This inspection was carried out on 23rd January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home enjoys a low staff turnover, which facilitates continuity of care. Although there are clear lines of accountability there is a relaxed and family atmosphere. Regular newsletters are collated and distributed. The home has a suggestion box located in the reception area. Very few complaints are made. Accommodation is provided in a century old building, which is tastefully decorated and furnished in an age appropriate style. The home has a reputation for provision of good standards of care.

What has improved since the last inspection?

The vacancy of activities organiser has not been filled but the senior carer has taken on the role resulting in a significant improvement in the in-house programme. The first floor hall has been redecorated. The manager`s office has been re-organised and a storage cupboard relocated resulting in improved spatial effect. Two bedrooms have been redecorated.

What the care home could do better:

The inspector was advised at the last inspection of the intention to appoint the deputy manager to the post of manager. The registered individual would then step down from the manager`s position. Senior officers are advised to action the planned changes. The deputy manager is advised to write to West Midlands Fire Service in order to gain a response to the query raised a significant time ago. Clarification would assist the home in taking appropriate action to address an outstanding requirement regarding access to the fire escape door located within the laundry room.

CARE HOMES FOR OLDER PEOPLE Hafod Residential Home 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR Lead Inspector Kath Strong Unannounced Inspection 23rd January 2006 10:15 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 DS0000016917.V279828.R01.S.doc Version 5.1 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. DS0000016917.V279828.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hafod Residential Home Address 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR 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 5607 0121 354 2616 Mr Alan Pearce Mrs Eleri Perry Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000016917.V279828.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Hafod Care Home provides accommodation in a large and sympathetically adapted Victorian building situated at the junction of Anchorage Road and Lichfield Road approximately one mile from the centre of Sutton Coldfield. There are good bus links from Birmingham and Lichfield. Personal care can be provided for up to sixteen persons who are aged 65 years or above. The home does not provide nursing care. There are 14 bedrooms, two of which are shared rooms, the home utilises these as single rooms, and the majority have en-suite facilities. Bedrooms are located on the ground and first floors and there is a shaft lift for access purposes. Communal areas are available on both floors, these are spacious, attractive, well appointed and in keeping with the age of the property. The dining area on the first floor is an integral element of the lounge. A conservatory leading off the ground floor lounge serves as a dining room. Assisted bathing facilities are strategically located on each floor offering a choice of bath or shower facilities. The home has a large enclosed and attractive rear garden. There is limited off road parking at the front of the premises. DS0000016917.V279828.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection; the outcome was determined by a variety of means. In depth discussions were held with the deputy manager who also assisted with the inspection process. Relevant documentation was examined including three care plans. Progress was assessed in respect of the requirements raised at the last inspection and any key standards that were not inspected at the last visit. A partial tour of the premises was carried out and staff practices were observed. Four residents were spoken with individually. At the conclusion verbal feedback was given to the registered manager and the deputy manager. The inspection was limited to only those standards considered necessary. In order to gain a full overview into the services provided it is recommended that this report should be read in conjunction with the report dated 27th September 2005. What the service does well: What has improved since the last inspection? The vacancy of activities organiser has not been filled but the senior carer has taken on the role resulting in a significant improvement in the in-house programme. The first floor hall has been redecorated. The manager’s office has been re-organised and a storage cupboard relocated resulting in improved spatial effect. DS0000016917.V279828.R01.S.doc Version 5.1 Page 6 Two bedrooms have been redecorated. 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. DS0000016917.V279828.R01.S.doc Version 5.1 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 DS0000016917.V279828.R01.S.doc Version 5.1 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): 3 The home uses a comprehensive pre-admission assessment tool to determine individual’s requirements and determine if the home is able to meet all of the identified needs. EVIDENCE: Since the last inspection the pre-admission assessment tool has been further developed to include a full assessment of needs. This assists the home in demonstrating it ability to provide the level of care required. Standards 1, 2, 4 and 5 were assessed at the last inspection and were fully met. DS0000016917.V279828.R01.S.doc Version 5.1 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 and 9 The health care records clearly define health care needs and provide good evidence of the services of external professionals. The system for the administration of medications serves to prevent harm to residents. EVIDENCE: Care plans include the pre-admission assessment and extra information on the discharge/transfer form and health synopsis. These provide the framework for the collation of in depth care plans. Subsequent conditions that have developed have been well documented and acted upon. The files were found to be satisfactory and include monthly reviews and mobility assessments. The home has further developed the risk assessment tool. Documentation revealed that the input of external professionals is actively sought and acted upon. The files include a section for recording dates and rationale of any admissions to hospital. It was found that although some improvements had been achieved the home was still experiencing some difficulties with inadequate written instructions on dispensed medications. The deputy manager was advised to write to the GP’s DS0000016917.V279828.R01.S.doc Version 5.1 Page 10 and the pharmacist requesting that creams supplied should give full instructions regarding frequency of application. Standards 10 and 11 were assessed at the last inspection and were fully met. DS0000016917.V279828.R01.S.doc Version 5.1 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): 13 and 15 Dietary needs are well catered for with a balanced diet and a varied selection for residents to choose from. EVIDENCE: Standards 12, 13, 14 and 15 were assessed at the last inspection and were fully met. An external entertainer is invited to the home every week to provide residents with movement to music. Residents had been invited to have Christmas lunch in a hotel and the home was currently organising an outing for four residents to go to Blackpool. Lunch was observed being served and it was determined that the high standard found at the last inspection has remained consistent. Particular attention is paid to presentation and provision of condiments and serving of vegetables in tureens for residents to help themselves. Bowls of fruit are placed in lounges to encourage residents to eat healthily. DS0000016917.V279828.R01.S.doc Version 5.1 Page 12 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 concerns are listened to and acted on. EVIDENCE: Standard 16 was assessed at the last inspection and was fully met. The home has a suggestion box located in the main reception for comments to be made. Residents meetings continue to be held regularly. The home had not received any complaints since the last inspection. The policy in respect of adult protection was examined at the last inspection and found to be satisfactory. The home has not completed the ongoing programme of staff training in this aspect of care. DS0000016917.V279828.R01.S.doc Version 5.1 Page 13 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, 24, 25 and 26 The quality of the accommodation is excellent and provides a warm, safe and comfortable environment. EVIDENCE: The premises are well maintained and furnished and decorticated to a high standard. The ground floor has a lounge with a dining/conservatory off. The first floor has its own lounge/dining room. All communal rooms are tastefully appointed and in keeping with the age of the property. There are numerous interesting features of the building, which add to the interest and overall appearance. The kitchen and laundry rooms are well equipped. A small room leading off the kitchen gives permitted access to residents and relatives to make refreshments. There are two shared rooms that are occupied on a single room basis. Bedrooms are furnished to a high standard and include personal items of DS0000016917.V279828.R01.S.doc Version 5.1 Page 14 furniture. Some rooms are very personalised, this was evidenced by the presence of many personal possessions and ornaments. All rooms have a lockable facility for safe storage and some rooms were noted to have their own telephone installed. Suited door locks have been fitted, residents may request to have a key. Ten of the twelve rooms have en-suite facilities. The home was found to be light and airy, warm, tidy and very hygienic throughout. Standards 21, 22 and 23 were assessed at the last inspection and were fully met. DS0000016917.V279828.R01.S.doc Version 5.1 Page 15 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 and 29 Staff numbers are adequate resulting in a motivated workforce who work towards improving the quality of life of the residents. EVIDENCE: As with the previous inspection the staffing levels were found to be acceptable to provide appropriate care for the current client group. The home also employs a separate ancillary team who have well defined roles and clear lines of accountability. The home has further developed the reference form by incorporating a date to be supplied by the referee in respect of the staff recruitment process. Standards 27, 28 and 30 were assessed at the last inspection and were fully met. DS0000016917.V279828.R01.S.doc Version 5.1 Page 16 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, 33, 35 and 38 Senior personnel have a clear vision for the management structure and long term strategy for the home. EVIDENCE: The registered individual/manager is a very experienced trained nurse and is well supported by a deputy manager. There are plans to appoint the deputy manager to the role of manager; she has in depth knowledge and day to day management experience. The planned changes should result in a smooth transition. The home completed a quality assurance system and has recently been awarded Investors in People. The home is requested to supply CSCI with a copy of the report. DS0000016917.V279828.R01.S.doc Version 5.1 Page 17 The arrangements for the safe storage, handling and recording of resident’s personal monies were found to be satisfactory. One element of health and safety procedures remains outstanding from the last inspection. The home must make safe the access to the laundry room for residents whilst ensuring acceptable egress via the emergency fire door. Advice was given that WMFS had not responded to the homes query regarding this issue. It is recommended that the home submits a further request for advice in writing. DS0000016917.V279828.R01.S.doc Version 5.1 Page 18 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 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000016917.V279828.R01.S.doc Version 5.1 Page 19 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 OP18 Regulation 13(6) Requirement Timescale for action 30/03/06 2. OP38 13(4)ac The registered person must complete the already commenced process of staff training in adult protection. N.B. This remains outstanding from the last two inspections. The registered person must 15/03/06 obtain advice from West Midlands Fire Service regarding a suitable means of preventing residents from wandering into the laundry room whilst ensuring safe egress via the fire exit. N.B. This remains outstanding from the last two inspections. 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 DS0000016917.V279828.R01.S.doc Version 5.1 Page 20 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 DS0000016917.V279828.R01.S.doc Version 5.1 Page 21 - 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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