Inspection on 30/08/05 for Hall Steads

This inspection was carried out on 30th August 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hall Steads 21/08/07

Hall Steads 17/08/06

Hall Steads 12/01/06

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 S72 7DP Lead Inspector Steven Vessey Unannounced 30 August 2005 10:30am th 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 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 J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hall Steads Address Stacey Crescent Grimethorpe Barnsley S72 2DP 01226 781525 01226 781308 www.bupa.com BUPA Care Homes (CFH Care) Limited No. 2741070 Beverley Hewitt N - Care Home with Nursing 90 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of DE(E) Dementia - over 65 (30) registration, with number MD(E) Mental Disorder -over 65 (3) of places OP Old age (60) Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons accommodated shall be aged over 60 years and above 2. 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) 3. Willowgarth House is registered for personal care (PC) 4. Ladywood House is registered for nursing care (N) Date of last inspection 13th October 2004 Brief Description of the Service: Hall Steads is a purpose built care home that accomodates up to 90 residents. The home is divided into 3 houses accomodating 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 pub etc. Extensive gardens surround the home. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately five and a half hours from 10:30 to 16:10 The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff and residents and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to ten staff and five residents in some detail. What the service does well: What has improved since the last inspection? The Statement of Purpose had been reviewed and information relating to staff and management qualifications had been included. The results of resident surveys had been published and were on display in the reception area. The carpet in Willowgarth lounge, and floor coverings in some bedrooms had been replaced. The garden outside Willowgarth had been improved with the recent creation of a sensory garden. An alternative type of hoist, which assists residents to stand, had been provided. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 standard(s) 1 and 3, standard 6 was not applicable at the home. Prospective residents are provided with the information they need to make an informed choice about where to live. Residents care plans included a detailed assessment of their needs. EVIDENCE: The Statement of Purpose had been reviewed and included the qualifications of care staff and management. Five care plans included a detailed assessment of resident needs carried out on admission to the home. Some care plans included information from the placing authority. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 standard(s) 7, 8, and 9 Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Medication was managed safely and securely stored. EVIDENCE: Five care plans included detailed information as to the actions required by staff to meet the needs of individual residents and were reviewed regularly. Risk assessments were in place for the administration of medication, the development of pressure areas, nutrition, moving and handling and the use of bed rails when needed. Individual risk assessments were in place when required for care management issues, for example smoking and challenging behaviour. Residents or their relatives had signed some of these risk assessments. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved, District nurses nominated the care team on Willowgarth for a “personal best” care team award, which is an initiative run by BUPA, the Registered Provider. The team were successful and gained the award for providing a high standard of care to residents. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 10 Records were kept of medication being received into and leaving the home. There were medication administration records for residents, which were completed appropriately, maintaining resident’s health safety and welfare. On Ferrymoor and Ladywood qualified nursing staff administer medication and on Willowgarth senior care staff have been appropriately trained to administer medication. Medication, including controlled drugs was stored safely and securely. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 standard(s) 12 Residents are given choice in many aspects of their lives, allowing them to maintain their independence and were happy with the activities on offer. EVIDENCE: Two activities co-ordinators are employed to provide activities for residents, staff spoken to stated that this works well and residents have a variety of activities to take part in. Staff stated that if residents do not want to or are unable to participate in the group activities on offer the activities co-ordinators spend time on a one to one basis to provide stimulation to all residents. Staff stated that there had been recent outings for residents and also entertainers visit the home. Residents spoken to stated that they could decide how to spend their day and were offered a choice of food at mealtimes, comments included “We are asked if we want a cooked breakfast”. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 12 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 standard(s) 18 Procedures are in place to protect residents from abuse, adult protection training for all staff would increase the level of protection for residents. EVIDENCE: Policies and procedures were in place relating to the recognising and reporting of abuse including whistleblowing. Staff stated that they would report any suspected abuse to their Unit Manager or the home manager. Some staff spoken to stated that they had attended adult protection training, others had not. The Deputy Manager stated that some senior staff are attending an adult protection training day and will then provide training for all staff. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21 and 24 The home was well maintained. The creation of a sensory garden had improved the outdoor communal facilities. However the provision of a smoke free lounge for residents is still needed to improve the indoor communal facilities. Suitable bathing facilities were in place, however the quality of care could be improved with the provision of more appropriate assisted baths and the provision of a shower for residents to use. Residents were happy and comfortable in their rooms. EVIDENCE: The home and gardens were well maintained. A sensory garden had recently been created outside Willowgarth. Residents and relatives stated that their bedrooms were comfortable and kept clean. Bedrooms had been personalised and residents stated that they had the furniture that they needed. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 14 There were adequate toilets and bathing facilities, however staff stated that these could be improved with the provision of a more appropriate bath on Ferrymoor and a shower for the use of residents on Ladywood. Residents stated that they were able to smoke outside or in a corner of the lounge, some residents were aware of plans to make this area into a more comfortable small lounge. Staff confirmed that plans were in place for this work to commence in the near future. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. The target of 50 of care staff with an NVQ level 2 qualified had almost been met and will be achieved when staff who are currently undertaking the qualification have been successful. A robust recruitment procedure was in place, protecting residents. Induction training provided is comprehensive and staff receive further training to assist them in meeting the needs of the residents. EVIDENCE: On Ferrrymoor the Unit Manager, a nurse and four care staff were on duty, on Ladywood, two nurses and four care staff were on duty and on Willowgarth, the Unit Manager and four care staff were on duty. In addition to this domestic, laundry, catering staff, two activities co-ordinators, an administrator and the maintenance manager were working around the home. Residents spoken to stated that there was sufficient staff on duty to meet their needs. Some staff stated that if there were more staff on duty this would give them sufficient time to spend with residents on an individual basis to enhance the overall quality of service. Training records showed that 48 of care staff employed at the home had completed the level 2 NVQ in care. Three staff files contained appropriate recruitment information including two references and CRB disclosures and POVA checks. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 16 Staff stated that they had received induction training and that there were good opportunities for training. Training records showed that nursing staff had opportunities to update their clinical skills, the Unit Manager on Ferrymoor stated that she had undertaken training in dementia care and was in the process of completing a work related degree course. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38. Effective quality monitoring systems were in place. In the main the health safety and welfare of residents and staff were maintained, however the excessive hot water temperature compromised the safety of residents. EVIDENCE: The operations manager has an office base at the home and is a regular visitor and provides appropriate reports to the Commission for Social Care Inspection. Some residents stated that there had been a residents meeting a long time ago, which resulted in a slight improvement in the quality of the food, but stated that they were not regularly asked their views about the home. The results of a resident survey had been published and were available in the reception area. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 18 Records were in place stating fire equipment had been checked, regular fire drills had taken place and that staff had received fire training. Staff confirmed that they had received fire and moving and handling training, promoting resident safety. Staff stated that in the main they had enough equipment to move residents safely and that this had improved recently with the provision of additional hoists on some units. Some staff stated that this could be improved if an additional hoist was provided for Willowgarth. Records were in place to show that the gas appliances and hoists had been serviced, the electrical testing had been carried and that water temperatures were checked on a regular basis, however the hot water temperature checked on the hand washbasin in a bathroom on Ferrymoor was 48 degrees centigrade. The maintenance manager was informed and this was rectified before the completion of the inspection. The maintenance manager stated that there was an ongoing programme of replacement of the thermostatic mixing valves throughout the home. Accident records were fully completed and the manager regularly carries out an audit of accidents. Information relating to accidents was recorded in residents care plans. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 2 3 x x 3 x x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 3 x x x x 2 Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 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. 1. 2. Standard 18 20 Regulation 13 12, 23 Requirement All staff must receive adult protection training. Communal space must be provided that includes a smoke free lounge (Previous timescale of 23.03.05 not met). Hot water temperatures must be regulated to around 43 degrees centigrade. Timescale for action 31.12.05 30.11.05 3. 4. 38 23 30.09.05 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. Refer to Standard 21 28 38 Good Practice Recommendations An assessment of the types of assisted baths and shower facilities should be carried out to ensure they meet the needs of residents. Fifty percent of care staff to be trained to NVQ level 2 or equivalent by 2005. An assessment of the moving and handling equipment on Willowgarth should be carried out to ensure it is adequate to meet the needs of the residents. Hall Steads J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 J51 S6482 Hall Steads V241325 30.08.05 UI Stage 4.doc Version 1.40 Page 22 - 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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