Inspection on 17/08/06 for Hall Steads

This inspection was carried out on 17th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/01/06

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 Cathy Howarth Key Unannounced Inspection 17 and 18 August 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.V300743.R02.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. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hall Steads Address Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP 01226 781525 01226 781308 firthj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) Post Vacant 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.V300743.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons accommodated shall be aged over 60 years and above 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) Date of last inspection 12th January 2006 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 car 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. Fees at the home currently range between £315 and £602 Information about the home is available from the reception and in welcome packs for new service users. Inspection reports produced by CSCI are displayed on each unit at the home. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over a period of two days, conducted by two inspectors. In addition to this site visit the inspectors also received information from the home in the planning stages. Questionnaires were sent to 18 service users before this inspection. 5 service users responded. These responses were generally positive about the service. Inspectors also spoke with two visiting health professionals as part of this inspection. Overall inspectors gained the impression that the service has had some difficult times in the past but under new leadership there are signs of improvements being made and on the whole a positive attitude within the staff team. Inspectors would like to thank service users and staff for their warm welcome throughout the site visit. What the service does well: What has improved since the last inspection? The environment at Hallsteads has improved, with the refurbishment of rooms on Willowgarth. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 6 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.V300743.R02.S.doc Version 5.2 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.V300743.R02.S.doc Version 5.2 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, 2, 3 The processes for admissions are comprehensive but the quality of preadmission assessments need to be monitored. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The service has clear policies regarding the admission of new service users. Preadmission assessments are routinely carried out on new service users. On the site visit however, the assessment for the most recent admission to Ferrymoor was poor. Other assessments seen were better but need to be more detailed especially where people may have complex support or nursing needs. There is a good level of information given to prospective service users and their relatives about the home and about BUPA. On admission every service Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 9 user receives a welcome pack containing detailed information about the home and what they can expect from the service. Service users who receive funding for their placements have not always had contracts provided. However this is changing now and private payers always receive a BUPA document outlining the terms and conditions of residence and a contract to be signed. These were found on files. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 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): 7, 8, 9 and 10 There are systems in place to manage health and personal care but some improvements are needed. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Care plans were found to be generally adequate, but recording against goals is of limited value for evaluation purposes. For example where concerns about feeding or fluid intake are identified then clear monitoring of this needs to be documented on files. It was noted the care plans are routinely evaluated however. It was noted on the sample seen, that goals were mainly around physical needs rather than social ones. However one or two important issues were found such as one person living on Willowgarth whose care plan indicated that she would like to visit her husband who lives on another unit. Unfortunately it was found that this was not being achieved on a regular basis. Monitoring of these important goals needs to be better to ensure that people Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 11 living at Hallsteads have valued opportunities. There was evidence of liaison with other health professionals such as district nurses. Of some concern was that the latest person admitted to Ferrymoor, had no care plan beyond a rather sketchy preadmission assessment. No risk assessments, moving and handling assessments nor guidance for giving ‘as required’ information. This was brought to the attention of the manager who responded promptly to rectify the situation but in future new admissions must have an initial care plan in place on admission or very soon afterwards. On Ladywood, the file examined showed that, the safe bathing plan was found to be a standard document rather than individualised to the service user. The home has a medication policy for the safe handling and administration of medication. On this visit it was found that while the system largely works well, there were some improvements to be made, in particular in relation to keeping stock balances for medication that does not get used up each month and for one or two service users there were gaps in medication records where it was unclear whether medication had been given. For ‘as required’ medication there needs to be a protocol indicating when the medicine should be given as directed by the GP. Staff who give out medicines have received training but for some of these this has been some time ago. It is recommended that refresher training is given to ensure the system is used according to policy. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 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): 12, 13, 14 and 15 Service users can exert some control over their daily lives, particularly where they are able to articulate their wishes. Contacts with families are encouraged and visitors are welcomed into the home. The quality of food is good but some organisational aspects of mealtimes could be improved. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: At Hallsteads there are activities workers employed to ensure that service users have opportunities to maintain and develop their skills and interests. Service users on Willowgarth were the most able to express their views about this. They were mainly positive about the range of activities, particularly highlighting the various outings and craft activities as something they enjoyed. On the first day of the site visit about a dozen people went to Pugneys Country Park for the afternoon. As well as group activities, the workers do individual activities with individuals. This is particularly the case on Ferrymoor where group activities are more difficult for people to become engaged in. Inspectors observed that on Ferrymoor, when activities workers were not Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 13 available there was a lack of activity within the unit. Some work should be done to engage people in daily activities where this is possible. Visitors are welcomed within the units, but opportunities for private conversation may be limited other than in service users’ own bedrooms. In Ferrymoor the smoking room was in the process of being adapted to provide a facility for visitors. There is seating outside the units, which is suitable for entertaining visitors in fine weather. Feedback from service users about the food was generally good. Service users said “I can have a cooked breakfast every day if I want”. Others said “there’s plenty of it”. This was confirmed by menus and by observations of inspectors. There were some concerns about food, however, which related to choice and to the organisation of mealtimes. On Ferrymoor it was disappointing to see that a trolley full of orange squash drinks was prepared before lunch and people were given this to drink unless they objected. This is not offering sufficient choice for service users. Also on Ferrymoor it was observed that service users with dementia were asked to choose between stew and dumplings or tuna bake, without any supporting communication devices such as pictures or being shown the food itself. It was a general observation that perhaps the staff working on this unit could use more aids for communication to improve the chances of individuals being able to understand what is being asked of them. Another issue was the interpretation of a vegetarian diet on Ferrymoor. One person had been recently admitted whose admission information indicated that she was a vegetarian. This person was being given fish at both meals observed by the inspectors. Staff need clear guidance in how dietary needs should be met and what special diets include or exclude. One service user who is diabetic complained that the choices were too limited, especially if a low fat or low cholesterol diet was required as well. On Ladywood, it appeared it was the norm for meals served from the heated trolley to be left on a dining table waiting for staff to come and get them when required for those who needed assistance with eating, which meant the meal was getting cooler. No menus were available on any of the units for people to know what was available for meals. This would be an improvement easily achieved but important for some service users. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 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): 16 and 18 Service users are mainly protected from harm by the systems within the home. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Hallsteads has a complaints procedure, which is widely displayed within the home and all complaints are logged, although some of these need to be written up more clearly in detail for future reference should this be required. Inspectors found evidence that the manager responds appropriately to any issues raised. In survey responses people indicated that they were aware of how to complain and who to speak to. Staff have had training in protecting vulnerable adults and whistleblowing and know what to do in these circumstances. The systems to protect service users from harm are working effectively. Where poor practice has been observed, staff have used whistleblowing procedures to highlight this. The manager has responded swiftly and looked into matters thoroughly when any issues have been raised using appropriate procedures and achieving satisfactory outcomes for service users and their families The management of service users’ money where it is held by the home is satisfactory, but two signatures should be made against each transaction for added protection. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 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 and 26 The environment at Hallsteads is improving. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: Although this is a large site with three separate units, the overall quality of the environment is good. There is a programme of updating in place and a rolling programme of routine maintenance. Just before this inspection, all the bedrooms on Willowgarth had been updated with new furniture and flooring and had been redecorated. This did cause some disruption to service users but generally there were few complaints about this from service users and most were very happy with their new rooms. One service user did point out that the new sinks, whilst very attractive, made it difficult for wheelchair users to be independent in using them. This should be taken into consideration in any future planning too. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 16 The home’s plans include a similar update of Ladywood in the future as funds allow. Communal areas are also being updated and new table linen is being bought for Willowgarth. Clinical waste is managed well throughout the home. Infection control systems work well. On the site visit the manager had just bought a new electronic device to trial to de-ionise the air in some areas where odour can be a problem from time to time. There are central laundry facilities and these operate well. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 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 Staffing at the home is adequate, both in terms of numbers and training of staff. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The home’s policy for recruitment is generally good. Staff are appropriately checked, through obtaining references and having a CRB disclosure before commencing work. Any agency staff are checked by the agency, who make a declaration to BUPA about their checks. Areas for improvement however are in making sure that any gaps in employment history are accounted for in writing and copies of certificates for qualifications are made when staff are recruited. Staffing rotas indicate that staffing levels are quite high. However all staff spoken to say they need more – especially on Willowgarth at key times like mealtimes. Inspectors noted that all grades of staff were seen to provide hands on care, including nurses. On Ferrymoor it was noted at mealtimes that despite there being, at one point, eight staff, there was still a problem in making sure everyone got their meals in a timely way. It may be helpful to look at organisation and planning for some of these key times to address these issues. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 18 The home has ancillary staff in adequate numbers. All areas were seen to be clean, meals provided on time and laundry returned to service users in a timely fashion. Training opportunities within the home are good. Staff receive a thorough induction programme, which is a standard programme throughout the organisation. The home has 50 of staff trained to NVQ2. Visiting health professionals who spoke with inspectors had praise for the staff, saying they have “brilliant staff here” and “what I like is they see you coming and are ready”. Inspectors identified that more specialised training in dementia may be beneficial for those staff that work on Ferrymoor in particular. Also some nursing staff identified that they need update training in techniques they do not use frequently. Hall Steads DS0000006482.V300743.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Management and quality assurance within the home is good. Service users’ monies are handled appropriately. Health and Safety is managed well generally although some improvements re needed in fire safety. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. EVIDENCE: The manager is well qualified and experienced in running care homes. Although she is not yet registered she is due to attend for a ‘fit person’ interview shortly after this inspection. Staff and service users reported that she has made a difference to the home since starting work there six months ago. Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 20 Finances held by the home on behalf of service users were examined and found to be in good order. They could be improved however with the use of two signatures to account for each transaction. BUPA operates good quality monitoring systems as a matter of routine. Resident satisfaction surveys are carried out twice every year. The last survey results from Autumn 2005 were available and the most recent ones from Spring 2006 were expected soon. The survey results indicated a high level of satisfaction amongst residents with respect to areas such as food, activities, the building and staff. In addition the organisation carries out regular monitoring of complaints, accidents, falls to pick up on potential problems. Monthly visits by a manager are carried out. Staff supervision systems and meetings for staff were not in evidence previously. However the manager has started having meetings and supervision for staff is planned for the near future. Health and Safety routines and practices were generally found to be good throughout the home. Systems for routine checks and maintenance seem to be well embedded practices within the home. One area for improvement is in ensuring that all staff participate in fire drills twice a year. The current practice is random rather than systematic to ensure this is achieved. The manager recognised the value of a more systematic approach and agreed to implement a plan to ensure this happens. Also it was noted that the fire register on two units was out of date, this must be kept accurately if it is to be useful in the event of a fire. Hall Steads DS0000006482.V300743.R02.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 1 Hall Steads DS0000006482.V300743.R02.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(1) Requirement Every service user should have at least an initial care plan on the point of admission or very soon afterwards. Improvements need to be made in management of medication to ensure the system is safe for service users. Improvements must be made in the provision of special diets and staff awareness of these. Gaps in employment history should be accounted for in writing. Copies of certificates for qualifications referred to in applications should be held on recruitment files. Staff should participate in fire drills a minimum of twice a year. The fire register must be kept up to date. Timescale for action 31/08/06 2 OP9 13 (2) 30/09/06 30/09/06 30/09/06 3 4 OP15 OP29 12 (3 and 4) 19 Schedule 2 5 OP38 23 (4) 30/09/06 Hall Steads DS0000006482.V300743.R02.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 3 4 5 Refer to Standard OP3 OP9 OP30 OP35 OP36 Good Practice Recommendations The quality of preadmission assessments should be monitored to ensure they are adequate. Staff should receive refresher training in the medication administration system. Staff should receive additional training to meet the specialist needs of service users. Where the home holds money for service users two signatures should be obtained to account for each transaction. Staff should receive supervision a minimum of 6 times per year. 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