Inspection on 12/01/06 for Hall Steads

This inspection was carried out on 12th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hall Steads 21/08/07

Hall Steads 17/08/06

Hall Steads 30/08/05

Hall Steads 13/10/04

Hall Steads 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Hall Steads Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP Lead Inspector Jayne Barnett-Middleton Unannounced Inspection 12th 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 Hall Steads DS0000006482.V268619.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. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hall Steads Address Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP 01226 781525 01226 781308 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) www.bupa.com BUPA Care Homes (CFH Care) Limited No. 2741070 Beverley Hewitt Care Home 90 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (60) Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Ferrymoor House is registered for dementia elderly (DE/E), mental disorder elderly (MD/E) - 30 places nursing (N) of which 5 can be personal care (PC) Willowgarth House is registered for personal care (PC) Ladywood House is registered for nursing care (N) Persons accommodated shall be aged over 60 years and above Date of last inspection 30th August 2005 Brief Description of the Service: Hall Steads is a purpose built care home that accommodates up to 90 residents. The home is divided into 3 houses accommodating up to 30 residents in each. Willowgarth provides personal care, Ladywood provides nursing care and Ferrymoor provides care for older people with mental disorder and/or dementia. The home is built on a single storey. There is a large care park. The home is situated on the outskirts of Barnsley. It is a short distance from public transport, shops the post office and local amenities. Extensive gardens surround the home. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Jayne Barnett-Middleton carried out this inspection over five hours. Beverley Hewitt, registered manager was present during the inspection. Opportunity was taken to make an inspection of the home, examine a sample of records and talk to six residents, two visitors and nine staff. The inspector wishes to thank the residents, staff and manager for their time and cooperation throughout the inspection process. What the service does well: There was a relaxed and friendly atmosphere within the home. Residents were comfortable to talk about the care that they received. The staff team were friendly, approachable and professional. The home was clean, tidy and odour free. Overall all areas seen were well maintained and pleasantly decorated. Furnishings were clean which promoted a comfortable and homely environment. The grounds to the home were well maintained and safe for residents. The residents were encouraged to make simple choices about their daily living activities. Residents spoke in detail about their daily routines and confirmed that they were flexible to their individual needs. Residents and relatives spoke positively about the staff team and the care that was provided. Throughout the day staff were observed to treat residents with dignity and respect. All residents seen appeared well cared for, they were clean, hair and nails had been attended to and male residents were shaved. The care plan format was of a good standard. The format included all of the required information and the layout was accessible and information easy to track. Two care plans checked were for residents who had resided at the home for only a short time. The information included to date was very detailed and had been reviewed regularly. A good programme of activities was in place that was appropriate for the needs of the residents. The company had recently provided an entertainment budget. The manager and staff commented that this provided a good opportunity to provide additional activities including external entertainment and day trips. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 6 Many of the staff employed have worked at the home for many years and therefore know the residents well and can offer them a consistent service. All staff spoke positively about the manager and it was evident that all were confident in her abilities to manage the home. Staff commented that they received very good support and this promoted good team work and provided a good working atmosphere. 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. Hall Steads DS0000006482.V268619.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 Hall Steads DS0000006482.V268619.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): 3 and 5. Residents were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. Residents and their relatives were given the opportunity to visit the home prior to their admission. EVIDENCE: A full needs assessment was carried out for all residents prior to their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. One relative said that they had been invited to visit the home prior to their mothers’ admission, to assess the quality, facilities and suitability of the home. They confirmed that the manager and staff had been “very helpful” in taking the time to show them around the home. The home does not provide an intermediate care service. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Care plans were in place for all residents. They were very detailed and included all of the required information. Residents received personal support, which promoted their privacy, dignity and independence. Resident’s physical and emotional needs were met. There was evidence that a range of healthcare professionals regularly visited the home to meet the resident’s needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: The care plan format was of a good standard. The format included all of the required information and the layout was accessible and information easy to track. Three care plans, one in each house, were checked. All detailed the specific actions required by staff to ensure that the residents care needs were Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 10 met. Two care plans checked were for residents who had resided at the home for only a short time. The information included to date was very detailed and had been reviewed regularly. Records of healthcare visits were maintained and these evidenced that healthcare professionals, eg general practitioner and chiropodist were visiting residents on a regular basis. Residents said that their healthcare needs were met and described the visits that they received. One resident spoke in detail how she was reliant on the staff in helping her to wash and dress. She spoke positively about the care that she received and said that the staff provided her personal care in a manner that respected her dignity. Risk assessments were in place, which clearly identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, which promoted the safety of residents. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of residents. Medication was checked on a sample basis. The systems in place were well managed and medication had been administered appropriately maintaining resident’s health, safety and welfare. Throughout the day staff were observed to treat residents with dignity and respect. All residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. One resident commented, “They make sure I am well turned out, they always give me a shave”. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Routines within the home were flexible and residents were encouraged to spend their day as they wished. A good programme of activities was in place that was appropriate for the needs of the residents. Residents were able to receive visitors at any reasonable time. A good choice of menu was offered and specific dietary needs were catered for. Residents were satisfied with the choice and quality of food offered. EVIDENCE: Residents confirmed that they could spend their day as they wished. Residents were observed to be spending time in the lounges or within the privacy of their bedroom. Staff spoke in detail about their daily routines and confirmed that they were flexible to the needs of the residents. Two activities co-ordinator were employed to provide activities for residents. A range of activities was provided on a regular basis in all three houses. Staff said that this arrangement worked very well and that the activities planned Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 12 were appropriate to the needs and abilities of the residents. The manager and staff said that the company had recently provided an entertainment budget. The manager and staff commented that this was positive and commented that this provided a good opportunity to provide additional activities including external entertainment and day trips. Residents were encouraged to maintain links with their family and friends. Residents confirmed that visitors were welcome at any reasonable time. Two relatives said that they visited the home regularly and that the staff always made them welcome. The kitchen appeared well organised and systems were in place to ensure that special dietary needs were catered for. Residents said that a good choice of menu was offered and said that the food was “ nice, good and we always get what we want”. Hall Steads DS0000006482.V268619.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): 16 and 18. The homes complaints procedure was clear and accessible, ensuring that any complaints made by residents and their relatives would be listened to and action taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of residents. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. The complaints procedure was displayed within the main building of the home and in all three houses. A record of complaints was maintained which demonstrated that no complaints had been made at the home since the last inspection. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Staff had recently received Adult Protection training enabling them to identify and report any allegations or incidents of abuse to tenants. One member of staff commented that the training had been very informative and useful. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 14 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, 23 and 26. The home was clean, comfortable and overall very well maintained. Residents were provided with an environment that was safe, accessible and homely. EVIDENCE: The houses were clean, tidy and odour free. All areas seen were well maintained and pleasantly decorated. Furnishings were clean which promoted a comfortable and homely environment. The grounds to the home were well maintained and attractive. The resident’s bedrooms were comfortable, individually personalised and furnished to meet their needs. All the bedrooms seen were clean and pleasantly decorated. All the rooms had been personalised by the resident with small items of furniture, photographs and mementoes, encouraging them to retain their own identity. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 15 Only one minor maintenance issue was noted. The ceiling fan in one bathroom in the Ferrymoor house was particularly noisy and this would interrupt the pleasure of a relaxing bath. A small smoking area had been created in all of the three houses and this now provided a smoke free environment for residents who did not smoke. There were adequate toilets and bathing facilities. The manager said that in addition to these there were plans to provide a further three showers which will improve the facilities available. Housekeepers were employed who confirmed that they were provided with appropriate equipment that enabled them to maintain a good level of cleanliness. Laundry facilities were sited away from food preparation and resident areas, to ensure that any soiled linen was not carried through areas where food was prepared and did not intrude on residents. Staff confirmed that they were provided with sufficient protection clothing, ie gloves and aprons to control the risk of infection. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 16 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): 28, 29 and 30. Many of the staff employed have worked at the home for many years and therefore know the residents well and can offer them a consistent service. The target of 50 of care staff with an NVQ level 2 qualification had almost been met. Staff had received training to meet the resident’s general and specific needs. A good range of training was available for staff. The home operated a recruitment policy that promoted the protection of residents. Staff files were well maintained and included all of the required information. EVIDENCE: Residents and relatives spoke positively about the staff team and described them as “very nice”, “approachable” and “all very good”. The manager commented that there was a low turnover of staff, which promoted a consistent quality of care to residents. Almost 50 of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of service users. The manager confirmed that 49 of the staff were NVQ qualified and that when the staff Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 17 who are currently undertaking the qualification are successful the target of 50 will be achieved. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included food hygiene, adult protection, moving and handling and first aid. Staff commented that a good range of training was available appropriate to their job role and that refresher training was offered to ensure that they were up to date with all the statutory training required by the regulations. A robust recruitment policy and procedure was in place. Two files checked contained a good range of information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. Hall Steads DS0000006482.V268619.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): 31, 35 and 38. Residents and staff benefited from the ethos, leadership and management approach. Staff morale appeared good and all staff spoke positively above the management team. Resident’s financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of residents and staff. EVIDENCE: The manager had experience within the caring profession that enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. All staff, residents and relatives spoke positively about the Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 19 manager and it was evident that all were confident in her abilities to manage the home. Staff commented that they received very good support and that this promoted good team work and provided a good working atmosphere. All records that were checked were very well organised, legible and met the required standard. Arrangements were in place for residents who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that residents were able to access their monies for personal items as they wished. Systems were in place to protect residents from financial abuse and regular audits and checks were carried out. The staff received regular training including fire training, moving and handling and first Aid, which promoted safe working practices and the health, safety and welfare of the residents and their colleagues. Hall Steads DS0000006482.V268619.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 ceiling fan in the bathroom must be repaired or replaced. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations 50 of all care staff must achieve a National Vocational Qualification (NVQ) level 2 in care. Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Hall Steads DS0000006482.V268619.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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