Inspection on 27/09/05 for Hafod Residential Home

This inspection was carried out on 27th September 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 Residential Home 08/10/09

Hafod Residential Home 20/04/09

Hafod Residential Home 30/04/08

Hafod Residential Home 03/05/07

Hafod Residential Home 19/09/06

Hafod Residential Home 23/01/06

Hafod Residential Home 01/03/05

Hafod Residential Home 28/09/04

Hafod Residential Home 24/02/04

Hafod Residential Home 16/10/03

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

CARE HOMES FOR OLDER PEOPLE Hafod Residential Home 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR Lead Inspector Kath Strong Announced 27 September 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 Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hafod Residential Home Address 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR 0121 354 6507 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) Alan Pearce Eleri Perry Care Home 16 Category(ies) of Old Age (16) registration, with number of places Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1 March 2005 Brief Description of the Service: Hafod Care Home provides accommodation in a large and sypathetically adapted Victorian building 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, 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 availble 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 and a conservatory off the ground floor lounge serves as a dining room. Assisted bathing facilities are startegically 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. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI 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 conduct an announced inspection; the outcome was determined by a variety of methods. In depth discussions were held with the registered individual/manager and the deputy manager. Two care staff were formally interviewed, one of which is also the activities organiser. The inspector also met individually with three residents, a relative and a close friend of a resident. Relevant documentation was examined including three care plans, which included case tracking in order to determine that the home was meeting all of the identified needs. A review of staff recruitment practices and the complaints procedure were carried out. A tour of the premises was undertaken and the serving of lunch was observed. What the service does well: The registered individual is also the registered manager. The home also has a deputy manager and it was evident that the two senior staff work closely in ensuring appropriate running of the home. The home enjoys a low staff turnover, which facilitates continuity of care. Observations revealed that a relaxed and family culture is present within the home. The home has an interesting and varied in-house and external activities programme, the content of which is influenced by residents. Accommodation is provided in a century old building, which is tastefully maintained. Regular newsletters are collated and distributed. The home has a suggestion box located in the reception are and has almost completed a quality assurance system. The home has a reputation for provision of consistently good standards of care. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 Residential Home E54 S16917 HafodRHome V244351 270905 AI 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 Residential Home E54 S16917 HafodRHome V244351 270905 AI 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, 5 and 6 Prospective residents are supplied with adequate written information for them to make an informed decision about the home. The pre-admission assessment tool does not contain sufficient detail for the home identify the full needs of prospective residents. EVIDENCE: Slight amendments were made to the statement of purpose and service user guide to ensure that full information is provided. All newly admitted residents are supplied with, irrespective of the funding arrangements, a comprehensive contract of terms of residency. The shortfalls in the content of the pre-admission assessment tool were discussed. The registered individual/manager confirmed that this would be addressed shortly. The home also completes a dependency level tool, which is reviewed every six months. The home carries out re-assessments in conjunction with external agencies, when it is determined that the home is no longer able to meet a residents full Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 9 needs. As a consequence residents may be requested to seek alternative suitable accommodation. New admissions are based on a month’s trial and subsequent review before a permanent placement is offered. Prospective residents and their family are encouraged to make extended visits to the home as often as they wish and to sample the meals and to circulate with residents and staff before making a decision about the home. The home does not provide intermediate care. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI 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, 10 and 11 Care plans are comprehensive, clearly identify care needs and the input of external professionals is actively sought and acted upon. Risk assessments are not sufficiently detailed to ensure that the health and safety of residents is adequately protected. The arrangements for the administration of medications are well managed promoting good health. Resident’s privacy and dignity is respected and ensured. EVIDENCE: The care plan of the latest admission and two sampled files were examined. They included appropriate details of physical and mental health needs, monitoring and regular reviews. The file of the most recent admission had not been fully established. Staff advised that they were working towards this, the resident was reluctant to provide information therefore, staff were dependent on the next of kin to supply full details. There was good documentary evidence of the involvement of external professionals and that their advice was being acted upon. Where appropriate risk assessments have been carried out it was noted that the tool utilised was not detailed enough. Discussions were held regarding how to address this issue. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 11 A relative said, “I have found nothing to complain about, staff are very chatty and have been very helpful”. A friend of another resident stated, “Can’t fault the home, she seems really happy here”. A resident said, “I love the home”. The system in place for the administration of medications within the home appeared to be safe but the written details of the issuing pharmacy need to be more accurate. The home was advised that the pharmacy should be contacted in respect of directions for the administration of creams, which must be clearly detailed. Residents confirmed that their privacy and dignity is respected at all times. Staff were observed using the preferred term of address and knocking before entering a bedroom. Very ill residents are given the opportunity to transfer to hospital or to remain at he home. This is carried out in conjunction with negotiations with the family and the GP. A full range of services is provided including the input of external professionals. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI 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) 12, 13, 14 and 15 The recreational programme and links with the community are good and support and enrich resident’s social and educational opportunities. Residents influence the day-to-day running of the home. Dietary needs are well catered for with a balanced and varied selection. EVIDENCE: The programme of internal and external activities is regularly reviewed and tailored to resident’s preferences. The newly appointed senior carer who is also the activities organiser was utilising the latter part of her shift in spending time with residents and eliciting individuals requests. Residents meetings are held regularly and are also used as a forum for discussing recreational pursuits. Due to the diverse interests, it was reported that residents had requested that in-house activities are decided on a day-today basis, external activities continue to be pre-planned. The home has a monthly outing to a pub for lunch and a Christmas outing was currently being arranged. One resident goes out independently. The home maintains daily recordings of recreation and those who participated. It was noted that some of the facilities available very rather old, the activities organiser said she intended to compile a list of items that could be purchased. A relative spoken with advised that she is made welcome at any time. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 13 The homes menu indicates that a good range of choices is offered for each meal. The inspector observed lunch being served. A glass of wine or sherry is offered prior to the meal. The meals were well presented and tureens of fresh vegetables were placed on the tables. Staff were helpful and discreet. Good rapport was noted amongst the residents. One resident spoken with said, “Food is fairly good”. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 14 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 home has a satisfactory complaints procedure. Arrangements for the protection of residents are not fully completed placing them at possible risk of harm or abuse. EVIDENCE: The homes written complaints procedure was found to be satisfactory, residents and relatives had free access to the document. The home has not received any complaints since the last inspection. The written documentation concerning adult protection is comprehensive including a separate whistle blowing procedure; these are supported by the Birmingham City Council multi-agency guidelines. The home has a rolling programme of staff training in this aspect of care but at the time of inspection not all staff had completed the training. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 15 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, 23, 24, 25 and 26 The overall quality of accommodation, furnishings and fittings are of a high standard throughout creating a comfortable, hygienic and safe environment. EVIDENCE: The premises are well maintained and decorated whilst ensuring a homely atmosphere. All communal rooms were tastefully appointed and in keeping with the age of the property. There are numerous features of the building that due to the age of the property are of interest and are aesthetically pleasing. The overall effect is appropriate for the age of the client group. The kitchen and laundry rooms were well equipped and had the required hygiene practices in place. A small room off the kitchen has permitted access for residents and relatives to make themselves refreshments. The two shared bedrooms are occupied on a single basis only. Bedrooms were noted to be very personalised including furniture and many personal possessions. The deputy manager was advised that where residents had Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 16 requested only chair in their bedroom that this must be documented in the care plan and regularly reviewed. All rooms included a lockable facility and suited door locks to respect resident’s privacy. Ten of the twelve rooms have en-suite facilities. Communal toilets are strategically located and there is a bathroom and shower room on each floor. Information was given that the bathrooms are rarely used since the installation of the new assisted bathroom on the ground floor, which residents have chosen to use. Random sampling of hot water outlets is carried out and the results recorded. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 17 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, 28, 29 and 30 Staff numbers and morale are good resulting in an enthusiastic team that works positively with residents to improve their quality of life. Staff have received adequate training for them to possess the knowledge and skills to deliver appropriate care. EVIDENCE: The staffing levels were determined to be satisfactory at all times of each day. The manager and deputy manager readily carry out practical duties and provide staff support and guidance. The registered individual/manager advised that extra staff are employed as dictated by the health care needs of individual residents. The home employs dedicated ancillary staff for housekeeping, laundry and kitchen and share the maintenance team with the sister home, which is located close by. At least 50 of the home’s care staff have completed NVQ level 2 training. The homes recruitment practices appeared to be comprehensive with one exception. It was noted that the reference forms forwarded to referees did not include a request for the date of completion. As a result it was impossible to ensure that references had been received before the prospective employee was offered a post. The registered individual/manager stated that she would address the problem. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 18 The home has a system of a rolling programme of staff training and any identified training which would be required to meet the needs of the current client group. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 19 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, 35, 36, 37 and 38 The manager is well supported by her senior staff in providing clear leadership throughout the home with all staff demonstrating awareness of their roles and accountability. EVIDENCE: The registered individual/manager is very experienced, she is a trained nurse and is supported by a deputy manager. It was evident during the inspection that they operate an ‘open door’ approach to residents, visitors and staff. Both staff and relatives commented on the good relationships and support they receive. A resident commented that she felt the deputy manager “Is marvellous”. Information was given that the deputy manager will be promoted to the manager’s position. The home has enrolled in the scheme Investors in People, which is due to be completed shortly. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 20 The system for the handling of personal finances on behalf of residents was noted not to be robust. Two persons must sign all transactions. The registered individual/manager was advised to develop a written procedure and ensure that staff are made aware of its contents. Staff receive regular formal supervision that is well documented. The home is advised that both parties must sign the form. Resident’s files are well maintained and securely stored whilst permitting staff access at all times. All relevant servicing and equipment checks have been carried out and up to date risk assessments were in place for the premises. Fire alarm and emergency lighting checks were being conducted and staff were receiving regular fire drills and training. COSHH products were safely stored. The home must make safe the access of the laundry by residents whilst ensuring adequate egress from the fire door. Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 21 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 3 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 x 2 3 3 2 Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 22 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. Standard OP3 Regulation 14(1)a Requirement The registered person must further develop the preadmission assessment tool to include all items listed in standard 3.3. The registered person must further develop the residents risk assessment tool to include the degree of risk, to whom and the specific actions to be taken to reduce or eliminate the risk. The registered person must complete the already commenced process of staff training in adult protection. N.B. This remains outstanding from the last inspection. The registered person must ensure receipt of dated references in respect of staff recruitemnt. The registered person must complete the already commenced quality assurance system. The registered person must ensure that two signatures are obtained for every financial transaction concerning residents personal monies. Staff awareness must be ensured by Timescale for action 10/11/05 2. OP7 13(4)bc 15/11/05 3. OP18 13(6) 30/11/05 4. OP29 19(1)a Schedule 2 24(1)(2) 15/11/05 5. OP33 15/12/05 6. OP35 13(6) 10/11/05 Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 23 the collation of a written policy. 7. OP38 13(4)ac The registered person must discuss with West Midlands Fire Service 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 inspection. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Hafod Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Birmingham & 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 Residential Home E54 S16917 HafodRHome V244351 270905 AI stage 4.doc Version 1.40 Page 25 - 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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