Inspection on 18/01/06 for Half Acre House

This inspection was carried out on 18th 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.

Other inspections for this house

Half Acre House 16/08/06

Half Acre House 26/05/05

Half Acre House 15/09/04

Half Acre House 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Half Acre House Higher Ainsworth Road Radcliffe Manchester M26 4JH Lead Inspector Julie Bodell Unannounced Inspection 18th January 2006 09:30 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 Half Acre House DS0000008404.V272549.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. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Half Acre House Address Higher Ainsworth Road Radcliffe Manchester M26 4JH 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) 0161 725 9876 0161 724 8642 halfacre@highfield-care.com Southern Cross Care Homes Limited Miss Sarah Elizabeth Ashton Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users to include: up to 32 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 26th May 2005 Date of last inspection Brief Description of the Service: Half Acre is a care home providing personal care only and accommodation for up to 32 older people. Half Acre is located approximately 1 mile from the centre of Radcliffe and 3 miles from Bury. It is on a bus route and has a number of shops and a pub nearby. The premises are purpose built on three floors with a passenger lift. Accommodation is provided in single rooms with en-suite facilities, with three former double rooms available to share should service users require this. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At this unannounced inspection, the inspector looked round the building, watched the social interaction between staff members and service users and practice issues. Talked to the registered manager, a staff member, five service users and a relative. Looked at documents and records of three service users and relevant health and safety documents. The inspector also looked at what action had been taken in relation to outstanding requirements made at the last inspection. Please see the previous inspection report for further information. What the service does well: What has improved since the last inspection? What they could do better: Increase the communal space available to service users in the combined lounge/dining room on the ground floor by building the planned conservatory. This will then provide service users with a safer day-to-day living environment where people are able to move about safely, without tripping over other people and equipment that allows privacy when conversations take place and allows service users to watch the television without constantly being disturbed. The organisation must make every effort to obtain the registered managers certificate to evidence that she has completed the Registered Managers Award. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 6 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. Half Acre House DS0000008404.V272549.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 Half Acre House DS0000008404.V272549.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): 1345 Appropriate assessments had been undertaken before service users’ moved into Half Acre by suitably qualified people to ensure that their needs can be fully met. EVIDENCE: There is a statement of purpose and service user guide available to service users and their relatives, gives information about Half Acre. Both documents have recently been reviewed and revised and been approved by CSCI. Prospective service users and or their families are encouraged to visit the Home. Half Acre has rooms to view that are available for prospective service users. The care files of three service users who recently moved into the Home were examined and appropriate assessments were in place. Two reviews had been held since the service users where admitted to the Home. Relatives at both the reviews commented that they were happy with the care their relative was receiving and both said that there had been an improvement in the service users’ mobility in the time they had been at the Home. There are quite a few Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 9 male service users at Half Acre. Prospective male service users saw this as an important consideration. No issues of concerns were raised at this inspection in relation to service users individual needs not being met. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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): 78 Care plans and risk assessments examined were seen to be in good order, these provide staff members with information to enable them to meet service users needs. EVIDENCE: Individual care plans were in place on the three service users care records that were examined. Care plans include areas of health, personal and social care needs. These are generally well written and offer clear instruction to staff members as to how they are to care for and support the service users. References to emotional needs are also made. Care plans are kept under monthly review. Service users families are encouraged to become involved in care planning and are involved in review processes. Evidence of changing needs was reflected in the plans. A range of health care risk assessments are in place including, pressure areas, moving and handling, nutrition, weight, continence and general risk assessments. District nurses provide input where appropriate. Service users have access to GP’s and domiciliary opticians, dentist and chiropody services. Equipment such as bed rails, pressure-relieving mattresses, air flow cushions, bed rails etc is provided as necessary. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 11 Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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): 14 15 Service users have been consulted about the food they receive and their preferences are to be included in the new menu. The poor lay out of the main dining/lounge area spoil this social occasion. EVIDENCE: The inspector spoke to five service users who all had a low level of need. Most of these service users spent the majority of their time in their rooms and only came down to the dining room for meals. They were able to pursue their own interests such as reading, painting, puzzles, watching sport on television etc. Some had their own telephone in their rooms and visitors were able to come and go. Their bedrooms were all highly personalised and felt homely. The dining areas are very compact and staff members had difficulty manoeuvring wheelchair users in and out of places available. There are only 22 dining places downstairs for a potential 29 service users. At the last inspection service users said that they were not always happy with the food they receive and that the dining area is “cramped.” There has been a meeting with service users about the menu and a list of their preferences has been made. The menu will now be altered to reflect the list, and small samples of less traditional foods such as lasagne and curry are going to be served as tasters to see if service users like them. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 13 The inspector joined the service users for lunch of cottage pie, carrots and swede, followed by pear and ice cream. The amount served was substantial and everything was eaten. Service users were offered an alternative on request, and a record of the alternative is kept. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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 the following standard(s): 18 Any concerns that are raised by service users and their relatives are taken seriously by the registered manager and are documented. They were confident that they would be listened too and that she would deal with any matters to their satisfaction. EVIDENCE: There is a comprehensive policy in place for the prevention of abuse. Adult protection forms part of the induction training for new staff members. A statement in respect of whistle blowing is included in the staff handbook and is available in the staff room. The staff handbook has recently been updated and redistributed to the staff team, which they have signed to say that they have received. Evidence was available to demonstrate that the registered manager took appropriate action when an allegation was made. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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): 20 21 25 26 Half Acre provides a clean and homely environment for the people living there in respect of bedrooms. However, there are concerns about the adequacy of communal space to the ground floor, which have an impact on the health, safety and comfort of service users, when the Home is full. EVIDENCE: Half Acre provides the people that live there with single bedrooms that are decorated and furnished to a good standard. The bedrooms are comfortable and in many cases highly personalised with residents own possessions. There is an enclosed patio area to the rear of the Home, which affords access to a bowling green. The service users enjoy watching bowling matches in fine weather. At the time of the last inspection there was only one shower available to up to 32 residents because of problems with the water supply in terms of heat and poor water pressure to the Parker baths. This has been addressed and both Parker baths are now in working order. There have also been concerns about Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 16 Legionella in respect of water supplies at these points. The hot water tanks to the kitchen and laundry have been cleaned and chlorinated. The registered manager said that as for as she was aware that these were the only water tanks in the building. The inspector advises that the registered manager contacts the local environmental health department for further information to ensure that all the correct action has been undertaken. The one bathroom on the ground floor is unsuitable for service users needs. This has been the case since April 2004. A number of towels were seen to be in poor condition and these must be replaced. Since April 2003 concerns about the lack space available to service users in the combined lounge/dining area on the ground floor have been raised. When the home is fully occupied, this area is overcrowded and cannot accommodate all service users necessary furniture, equipment, visitors and activities taking place, e.g. staff moving service users, ability to watch television and talking to people in private and raises issues over safety and comfort of service users i.e. trip hazards. At previous inspections the organisation agreed that this was the case and the planning department, in February 2004, passed the plans for the new conservatory to be built. The inspector had expressed concern that if the work did not take place before the unset of winter the project, which funding had been agreed with the former owner, will be put back for another year. This work is yet to be undertaken. Consideration during alteration, needs to be given to the adequacy of present storage arrangements for wheelchairs, stand aids, etc that occupy corridor areas. The registered manager and two members have painted the lounge to good effect. The registered manager said that the outstanding fire requirements made at the Fire Officer’s visit on 14th April 2005 have now all been addressed. Service users have the specialist equipment they need. However the nurse call is not sounding on the second floor corridor and this has been the case since August 2005. This matter must be addressed as soon as possible. The Home is kept clean to a good standard. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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 28 29 30 Induction training is available to staff members has improved as well as opportunities to access NVQ training. Staff members need to complete NVQ training to ensure good occupational care standards. EVIDENCE: There are currently two care staff vacancies. There is a full complement of support staff. Agency staff are used on only a very occasionally to cover last minute sickness. The staff team is described as stable and working well together. All staff members have a CRB or POVAfirst check, through the company’s personnel section. Recruitment files have been brought more into line with the requirements, though more work remains to be done to ensure that a full employment history is given and the reason for any gaps is evidenced. An induction format has been introduced which is in line with TOPSS. Five members of the day staff hold NVQ Level 2, approximately 35 . All other staff members, bar a new the new member of staff, are enrolled on NVQ Level 2 but no progress has been made due to the constant changes in training providers. Every effort must be made to ensure that the present improvements are maintained to ensure the establishment of sound occupational standards. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 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): 31 35 38 The registered manager is aware of her role to promote and safeguard the health, safety and welfare of the service users. The organisation has been slow to respond to requirements that have been agreed. EVIDENCE: The registered manager has completed the Registered Manager’s Award, however she does not have a certificate to evidence this because the work has not been externally verified due to an unpaid bill on the part of the organisation. This situation has prevailed since June 2004, and is unacceptable. Financial arrangements of two service users appeared to be in order, though held in a “pool” account, which may conflict with Data Protection. The registered manager has conducted a review of the quality of care provided by Half Acre. Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X 2 2 2 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement That the registered provider takes the necessary action to increase communal space to the ground floor including consideration to improve storage of equipment such as wheelchairs, hoists etc. (Timescale outstanding from April 2003.) That the registered provider addresses the issues relating to the ground floor bathroom. (Timescale outstanding from April 2004.) That where necessary the towels that are in a poor condition are replaced. That the nurse-call system that has not been in full working order since August is repaired. That the local environmental health department is contacted to ensure that all appropriate action has been taken in respect of Legionella. (Ongoing in part.) That 50 of all care staff are trained to NVQ Level 2 by 2005. (Ongoing) DS0000008404.V272549.R01.S.doc Timescale for action 30/04/06 1. OP20 23 2. OP21 23 30/04/06 3. 4. OP21 OP22 16 13 31/01/06 31/01/06 5. OP25 13 31/01/06 6. OP28 12 30/04/06 Half Acre House Version 5.1 Page 21 7. 8. OP29 OP31 19 8 That a full employment history is obtained for staff members and evidence of explanation for gaps. That the issues surrounding the Registered Managers Award certificate are resolved. 31/01/06 31/01/06 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 Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Half Acre House DS0000008404.V272549.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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