Inspection on 20/09/07 for Halcyon Court Nursing Home

This inspection was carried out on 20th September 2007.

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

Halcyon Court Nursing Home 28/08/08

Halcyon Court Nursing Home 03/10/06

Halcyon Court Nursing Home 07/12/05

Halcyon Court Nursing Home 06/09/05

Halcyon Court Nursing Home 12/11/04

Halcyon Court Nursing Home 30/06/04

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

CARE HOMES FOR OLDER PEOPLE Halcyon Court Nursing Home 55 Cliff Road Leeds Yorkshire LS6 2EZ Lead Inspector Hebrew Rawlins Key Unannounced Inspection 20th September 2007 10:30 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 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 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. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halcyon Court Nursing Home Address 55 Cliff Road Leeds Yorkshire LS6 2EZ 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) 0113 2743006 0113 2307326 www.anchor.org.uk Anchor Trust Ms Marie Hennigan Care Home 71 Category(ies) of Old age, not falling within any other category registration, with number (71), Physical disability (5) of places Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The 5 places for PD are for the use of specific named service users only. One specific service user under the age of 65, named on variation received on 18/9/06 may reside at the home. 3rd October 2006 Date of last inspection Brief Description of the Service: Halcyon Court is owned by Anchor Trust, a registered charity. Marie Hennigan manages the home on their behalf. Halcyon Court is situated in a residential area of Leeds. The home has a large parking area. It is within easy reach of the city centre. Public transport is readily available a short walk from the home. There is a wide range of local amenities. The gardens to the rear of the home are accessible to service users and provide a seating area. To the front there is a small garden with planted raised beds and pathway. Accommodation is situated on four floors and is split into different zones, all of which are named. A passenger lift is provided, in addition to the stairwells, which allow access to all floors. There are eighteen double bedrooms. However, these are used for single occupancy on the whole. There are a number of communal bathroom and toilet facilities. Sixteen bedrooms have en-suite facilities. There are three lounges, two large dining rooms and a smaller dining area available for residents and their visitors. The home is registered to accommodate up to seventy-one older people. There is a temporary contract to provide care for people who have been discharged from hospital and are waiting for alternative accommodation in the community. (Referred to as intermediate beds). The home is staffed over twenty-four hours by a team of nurses, carers, domestics and catering staff. There is a senior on duty at all times with back up from the on call managers. The weekly fees range from £387.91 to £578.94. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection in September 2007. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. Information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home from 10.30 until 17.30 on 20th September 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit a number of documents were looked and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information about the home. Survey forms were sent out before the visit to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Feedback at the end of this inspection was given to the manager. Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: The home provides good care for people and supports them to maintain their independence. There is good information available about the home. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 6 Comments from relatives/visitors and a visiting health care professional were all positive. Relatives made comments such as “you can talk to the staff they understand” “so far I have seen a top quality service”. A visiting health care professional said “staff seem to be polite to people using the service and to other members of staff”. People who use the service confirmed that they could see visitors at anytime helping them keep in contact with family and friends. Staff were seen helping people retain their independence in daily tasks. A person living at the home said, “The people who work here are really good”. There is a good programme of ongoing training and development. This ensures that all staff have the skills and knowledge they need to carry out their work. All the people spoken with said the food at the home was very good. There is a choice at each mealtime. Staff were observed in the dinning rooms at lunchtime assisting people who needed it and being available throughout the lunchtime period. What has improved since the last inspection? What they could do better: The refurbishment that has started must be completed and other areas that are showing signs of wear and tear should be redecorated. The level of activities provided on a day to day basis, do not always meet peoples’ needs, which means that some people are left with little stimulation. There was no photograph on the front medication records of some peoples file, which is good practice and helps support staff administering medication. A number of the cutlery use by people in the home is showing signs of wear and tear. Things like plastic cups/glass that are badly stained should be replaced regularly. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 8 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 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to visit the home and have access to good written information about the home. A pre-admission care assessment is undertaken prior to admission. This results in placements that are suitable. EVIDENCE: Eight care plans were looked at. There were assessment details in the eight records sampled, the new home’s pre-admission assessment provide sufficient information about the person’s needs and strengths in all aspects of their care, and had enough information to form the basis of a care plan. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 10 The manager produced an up to date welcome pack, which she said is made available to prospective people thinking of coming to the home, their relatives and social workers. People spoken with said they and their relatives had the opportunity to visit and assess the facilities and suitability of Halcyon Court. Eight care plans were looked at in detail and in all eight there was a signed contract showing the terms and conditions of residency. In respect of the people case tracked there was evidence of comprehensive pre-admission assessments. It provides details of peoples condition, health and other professional’s involvement with the individual. People who are referred for intermediate care are helped and supported to return to their home as soon as possible. One person spoken with was on that day was going back to his home for a visit to access his progress. He was extremely excited at the prospect of returning home. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples care needs are met in a way that respects their privacy and dignity. Photograph of people should be on the front of their medication records, which is good practice and helps support staff administering medication. EVIDENCE: There was evidence in records that people have access to GPs (General Practitioner), chiropodody, dental and optical services. Survey forms returned from GPs state that the home manages peoples’ health care needs well and always seek to give clients privacy. However one GP did state in the survey returned ‘ do receive a lot of phone calls compared to other homes-this can sometimes by due to more poorly patients but it seems to be “box ticking” on part of staff i.e. staff seem to ring to cover self rather than genuine care for patient. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 12 The medication system was examined. Storage facilities are secure and the accompanying record sheets have been accurately completed. However not all the people in the home has a photograph available on the recording charts to check against the medication being given. Care plans address personal, health and social care needs, and the manager is continuing to develop them so that they provide more detailed information about each person. Care plans include information on spiritual and cultural needs. There are risk assessment in place for falls, nutrition, and the risk of developing pressure sores. People’s wishes in respect of end of life care are recorded. From discussions with people living at the home and from the returned completed survey forms it is clear that they feel that their dignity and privacy are respected. People living in the home looked well cared for. During conversations with relatives two people said they had no concerns about their mother’s health care needs, and that the home responded to any changes in her condition. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good and varied diet is provided. A number of the cutlery use by people in the home must be replaced. The home has a relaxed and informal atmosphere that promotes flexibility and visitors are made to feel welcome. The level of activities provided on a day to day basis, do not always meet peoples’ needs, which means that some people are left with little stimulation. EVIDENCE: The home display a monthly list of planned activities taking place in the home each month. However this is in small print, which makes it difficult for all the people to read. They have a regular monthly entertainer who visits for a singa-long. They have a 4 weekly music and movement session that is run by Motivation and co. There are also one-to-one sessions for manicures, nail painting, shopping and walks. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 14 Comments from discussions with people at the home and some surveys returned indicated that these did not always meet their needs and expectations. “There are activities but I don’t always know what they are”, “My health restrict me”, “Something that stretches my mind. During the inspection, those people who were unable to occupy themselves had little stimulation, other than at times when care was delivered. The manager said she is having difficulty recruiting a full time activity coordinator. All the people spoken with confirmed that they are able to get up and go to bed as they wish and that visitors are able to visit them at anytime. All the people spoken with said the food at the home was very good. There is a choice at each mealtime. Staff were observed in the dinning rooms at lunchtime assisting people who needed it and being available throughout the lunchtime period. However some of the cutlery seen being used was badly stained such as plastic cups and glasses. People are given two main choices each mealtime. In addition to the daily menu’s that were displayed in small print other options are also available dependent what people wanted. Special diets are catered for such as diabetics, gluten and fat free diets. Drinks are available throughout the day. Staff were seen taking drinks around the home. People said that they are offered plenty of drinks throughout the day. Relatives said that they were always offered a drink by staff, which made them feel welcome in the home. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that their complaints and concerns will be dealt with and are safe living in the home. EVIDENCE: The home has a comprehensive complaints procedure in place, which is made available to people as it displayed on the reception area. The home records all complaints they receive. No complaints have been made either to the home or the Commission For Social Care Inspection. People said that they were aware of how to raise any concerns. They said they would approach care staff or the homes management team and they were confident that they would put things right. Comprehensive policies and procedures on the protection of vulnerable adults were seen including the local multi-agency agreement. Staff have recently undertaken training on recognising abuse. In discussion they all appeared confident in the action to be taken should abuse be suspected or alleged. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 25 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in an environment that is clean, comfortable and unpleasant odour appears to be under control. When the refurbishment is completed the improvement will benefit all the people using the service as well as staff. EVIDENCE: Areas of the home seen were clean with the exception of the staff areas. There were no unpleasant odours throughout the home. The refurbishment of the home has started and when complete they will be an improvement of the kitchen facilities, the laundry facilities and all of the communal areas. Improvement to several bedrooms and bathrooms will also take place. Majority of bedrooms are very personalised with photos, ornaments etc. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 17 The home has been involved in an MRSA research project that has provided external advice and training on hand washing and infection control. This has reduced the number of the home-acquired infections. They were liquid soap and paper towels available in all rooms. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Well-trained and competent staff meets the needs of the people living in the home. Those people are also protected by the recruitment procedures. EVIDENCE: The home has a robust recruitment procedure in place, which is supported by the organisation recruitment team. They were clear evidence of job profiles and formal interview process. Over 50 of the staff have achieved a National Vocational Qualification (NVQ) in care at level 2. There are 4 NVQ assessors employed in the home and 2 internal verifiers also employed in the home. Duty rotas indicated that there is sufficient care staff on duty to meet the needs of the people living in the home. Staff have regular supervision and all the necessary checks are carried out before staff start work at the home. The home continues to let us know about things that have happened and to date they have shown that they have managed issues well. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed Health and safety of people living in the home and staff is promoted and protected. EVIDENCE: The registered manager is well qualified with many years management experience. She provides strong leadership and support to the staff team. The returned annual quality assurance assessment showed that servicing of equipment takes place as required and a selection of service certificates were Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 20 seen, along with the records of fire alarm tests which show a different actuation point is tested each time. Accident records in individual files and accident monitoring system in place. Training records show that all staff have received training in health and safety. Staff were observed using correct methods of moving and handling. There is an established system in place for supervision of the staff and the person carrying out supervision has been trained to do so. The format used indicated that personal development; training and goal setting are amongst the topics covered. Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 3 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23 Requirement The refurbishment that has started must be completed and other areas that are showing signs of wear and tear should be redecorated. Deep cleaning is required in the kitchen and a number of wall tiles replaced (raised last at inspection but work is due to start). Attention is required to the stairs carpet (raised last at inspection but work is due to start). The areas of the home that is showing signs of wear and tear must be addressed (raised last at inspection but work is due to start). A number of the cutlery use by people in the home is showing signs of wear and tear. Things like plastic cups/glass that are badly stained should be replaced regularly. Deep cleaning is required in the staff rooms. Timescale for action 18/01/08 2. OP19 23 18/01/08 3. 4. OP19 OP19 23 23 18/01/08 18/01/08 5 OP15 16 01/12/07 6 OP26 23 01/12/07 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 23 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. 2 Refer to Standard OP9 OP12 Good Practice Recommendations Photograph of residents should be placed on the front of resident’s medication records. The level of activities provided on a day to day basis, should be improved they do not always meet peoples’ needs, which means that some people are left with little stimulation. The manager should make sure menus and activities are displayed in large print so people know what is taking place. 3 OP12 OP15 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Halcyon Court Nursing Home DS0000055003.V332645.R01.S.doc Version 5.2 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. 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!