Inspection on 07/12/05 for Halcyon Court Nursing Home

This inspection was carried out on 7th December 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

Halcyon Court Nursing Home 28/08/08

Halcyon Court Nursing Home 20/09/07

Halcyon Court Nursing Home 03/10/06

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 Karen Westhead Unannounced Inspection 7th December 2005 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.V269248.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. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 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 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.V269248.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 5 places for PD are for the use of specific named service users only. 6th September 2005 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 three 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. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all care homes. This was the second inspection of this home for the 2005/2006 inspection year. The first visit took place on 6th September 2005. This inspection was unannounced and was undertaken by one inspector. The visit started at 10.30am and finished at 4.45pm. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 6th September 2005. At that time there were two requirements and one recommendation. One of these remains outstanding as the fire safety equipment had not been tested as required. The recommendation involved the labelling of residents clothing. Steps had been taken to address this. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the administrator. Those standards which were not assessed at the last visit were focused on during this inspection, therefore over the twelve month period all standards have been reviewed. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. In addition, information leaflets were given to residents with a brief description of the CSCI function and details of how to contact the inspector. What the service does well: The manager and staff team make appropriate arrangements to ensure people moving into Halcyon Court are properly assessed and receive information prior to their stay. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 6 Residents receive a good standard of healthcare support and healthcare professionals are consulted and asked to visit as required. It was evident during the course of the visit that residents are treated with respect and are cared for in a professional, friendly and caring manner by staff. Without exception, all residents and visitors spoken with were very positive about the manager, nurses and staff team. Comments related to their commitment to their respective roles and their levels of understanding when caring for older people. 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. Halcyon Court Nursing Home DS0000055003.V269248.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 Halcyon Court Nursing Home DS0000055003.V269248.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 5 The admission’s procedure is comprehensive and effective; therefore residents have the information they need to make an informed choice about the home. They are encouraged to visit the home prior to admission where possible to assist in the decision process. EVIDENCE: Information is available to prospective residents and their relatives prior to them visiting the home, therefore enabling them to make an informed decision about their stay. This is not always the case when the resident is occupying an intermediate bed. However, staff do try their utmost to ensure the resident is familiar with the running of the home as soon as they arrive and that they are monitored to ensure they are settling in. The statement of purpose is revised during management meetings and amended as required. All residents are provided with printed documentation on the point of admission and this includes a guide to the home, explaining what they can expect and there are some useful contact numbers and names to refer to if they have any concerns or comments. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 9 The inspector viewed a random selection of resident files. All contained a preadmission assessment. Staff on duty confirmed that where appropriate permanent residents are given the opportunity to visit the home and were admitted for a trial period in the first instance. Four residents recalled their experiences of ‘moving in’, when talking to the inspector. They each said they felt the process had been conducted in a logical and straightforward manner. Each said they had not felt pressurised to make up their minds; one resident in fact had opted to lengthen the trial period to ensure she was sure about her decision. One resident said they had come to Halcyon Court on a temporary basis and decided to stay permanently once she had settled in. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 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 the following standard(s): 8 and 11 There is clear written information for staff to follow in the event of a death in the home. The environment allows for privacy and dignity for residents who are ill. EVIDENCE: Staff spoken to during the visit were compassionate and professional when speaking about this stage in a residents life. They understood the importance of ‘getting it right’ and gave examples of the experiences they have had at Halcyon Court. They commented on the positive support given by senior staff and each other during and after the death of a resident. A course on death and bereavement is available to all staff and some base line information is provided on induction. At the time of the visit three staff were doing a three-day course entitled the ‘end of life’. This was being run by a local hospice. The procedures allow for staff to call on specialist services if the resident is wishing to die at the home so that they can continue to provide the appropriate care. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 11 A complaint was made to the inspector during the visit, about choice of food and lack of attention to personal care. (This is noted again in standard 17) The inspector agreed with the complainant to discuss the issues with the senior staff on duty straightaway. The issue with the food was said to be an ongoing matter. However, the complaint regarding personal care had to be dealt with immediately. This was done. The situation was seen as poor practice and the inspector asked for assurances that the matter would be dealt with formally. The senior on duty agreed to talk to staff directly for an explanation and monitor the situation thereafter. The complainant was satisfied with the action taken. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 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 the following standard(s): Standards were assessed at last inspection. Standards were assessed at last inspection. EVIDENCE: Halcyon Court Nursing Home DS0000055003.V269248.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): 17 Resident’s rights are promoted and respected. There is a robust complaints procedure, which encourages residents and their representatives to bring matters of concern to the attention of the manager or the organisation. EVIDENCE: The practices and procedures in the home give residents the opportunity to exercise their full rights. For residents who have limited understanding or find communication difficult advocacy services are offered routinely. Representatives from Age Concern are regular visitors in the home and actively work to ensure residents are supported. At the time of the visit, a representative was in the home working with a resident. As she left she commented on the openness and willingness of staff to seek her advice. During the visit the inspector saw many examples of residents being empowered to make decisions about their lives, where to sit, what to eat, whether they wanted to be bathed are just a few. A training course available to staff covers the principles of care, rights of the resident, prevention of abuse and adult protection. Since the last inspection there had been two complaints made directly to the home. Both had been resolved by the home to a satisfactory conclusion. A complaint was made to the inspector during the visit, about choice of food and lack of attention to personal care. The inspector agreed with the complainant to discuss the issues with the senior staff on duty straightaway. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 14 The issue with the food was said to be an ongoing matter and the home and catering staff are working with the resident and family to resolve this. However, the matter regarding personal care had to be dealt with immediately. This was done. The situation was seen as poor practice and the inspector asked for assurances that the matter would be dealt with formally. The senior on duty agreed to talk to staff directly for an explanation and monitor the situation thereafter. The complainant was satisfied with the action taken. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 22, 23, 25 and 26 Resident bedrooms are personalised and provide a good standard of accommodation. There are ample toilets and bathrooms to allow residents a choice of where and when to use them. Appropriate aids and adaptations have been fitted to maintain residents’ independence and dignity. Fire doors must not be propped open and odour control must be monitored. EVIDENCE: All radiators have now been fitted with guards those making them safe. Toilets and bathrooms are clearly marked and conveniently situated for use during the day and night. Some residents have the benefit of ensuite facilities in their bedrooms. During the inspection a fire safety officer was carrying out a check of the premises. The manager’s office is small and to allow ease of access and ventilation the staff prop the door open with a chair, this is contrary to fire regulations and may compromise health and safety. The fire safety equipment had not been tested since the beginning of August 2005, according to the fire register. This is wholly inadequate and must be rectified. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 16 During a tour of the premises there was an unpleasant odour on the sixth floor. Staff must remain diligent in the their efforts to attend to soiled linen and furniture. Notwithstanding these comments the home was found to be generally clean and tidy. One resident said they did not find the armchairs very comfortable. The resident said because they had a ‘big frame’ they found the chairs small when sitting for any length of time. The inspector agreed to raise this on behalf of the resident, with the senior on duty. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 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 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 The numbers and skill mix of staff were sufficient to meet the needs of residents. Staff on duty were able to demonstrate a good knowledge of the resident group. EVIDENCE: At the time of the visit there were adequate staff to care for the residents living at Halcyon Court. There were 52 residents on the register. The senior on duty said they were fully staffed apart from needing two full time carers. Existing staff were covering the shortfall in hours as the organisation had provided an incentive scheme for them not using agency staff. The senior on duty said they were aware of the implications of working long hours and continually monitored the shifts staff were working to make sure they were not overstretching themselves. Staff confirmed they received regular support and supervision from senior staff. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 18 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): 32, 34, 35, 36 and 37 Residents and visitors knew the name of the manager and who she was. The manager is seen as open and professional. Staff and residents have a voice by way of monthly meetings. EVIDENCE: The manager is visible and works alongside staff and residents, this was the impression given to the inspector during conversations with residents, staff and visitors. The home is seen to actively promote equal opportunities and polices are written with an underpinning of diversity principles. This is demonstrated with the different cultural slants given to food, music and entertainment and the recruitment and selection process. Staff meetings are held monthly and minuted. The agenda items show a wide range of discussion points and evidence that senior staff want to maintain high standards across the board. Residents also have monthly meetings which are typed up and distributed around the home. The agenda is set by residents but Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 19 with the assistance of staff. For those not attending, items are added for discussion in their absence. The organisation produces a business plan which is regularly reviewed. There were no adverse comments made about the viability of the home or organisation. Resident’s finances are organised according to the company procedure. Residents who are unable to look after their own money are able to deposit money for safekeeping. All money retained is receipted and all transactions are recorded. For some residents it has been necessary for a third party to be appointed to deal with their monies in view of their limited understanding or vulnerability. There is restricted access to the safe. Financial transactions are recorded on a database which is audited by the company. Of the 52 residents living at the home currently, 35 have monies retained. All the money is kept in separate purses and an individual record is kept. The inspector checked four random balances. These were found to be correct. Residents spoken with who were able to pass comment said they preferred to have their personal allowance saved for them and that they could have access to it if they needed to. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 20 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 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 2 X 3 3 3 X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 3 3 x Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 21 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 17(2) Sch 4 Timescale for action All fire safety equipment must be 23/02/06 tested regularly to ensure the health and safety of residents is not compromised. This standard is outstanding from the last inspection on 6th September 2005. The registered person must maintain the personal care of each resident and make proper provision for them. The registered person must not compromise the health and safety of residents by propping fire doors open. The registered person must make suitable arrangements for keeping the care home free from offensive odours. Requirement 2 OP8 12(a) 23/02/06 3 OP19 23(4) 23/02/06 4 OP26 16 23/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 22 No. Refer to Standard Good Practice Recommendations Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Halcyon Court Nursing Home DS0000055003.V269248.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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