Inspection on 06/12/05 for Hall The

This inspection was carried out on 6th December 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 The 07/11/06

Hall The 02/03/06

Hall The 01/03/05

Hall The 03/11/04

Hall The 05/02/04

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

CARE HOMES FOR OLDER PEOPLE Hall The Chestnut Ave Thornton Le Dale Pickering North Yorkshire YO18 7RR Lead Inspector Gill Sample Unannounced Inspection 6th December 2005 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 The DS0000007741.V271158.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. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hall The Address Chestnut Ave Thornton Le Dale Pickering North Yorkshire YO18 7RR 01751 474789 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) Thornton Le Dale Hotel Limited Mrs Johanna Eva Mary Mackenzie-Rollinson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st March 2005 Brief Description of the Service: The Hall is a care home providing personal care and accommodation for 35 older people. It is owned by Thornton Dale Hotel Limited. Mrs. Johanna Mackenzie-Rollinson is the registered manager of the home. The home is centrally located in the village of Thornton-le-Dale close to shops, public transport and other amenities. The building is a former hotel and stands in extensive grounds overlooking the countryside. There are 25 single bedrooms and 5 double rooms with en-suite facilities. There is a passenger lift and a stair lift as well as aids and adaptations to assist service users. A public house is separately located within the building and the service users can use this facility. Adequate communal lounges are provided within the main building. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of an unannounced inspection which was made on 6th December 2005. The inspection focussed on a number of key standards and those requirements and recommendations made at the last inspection. There were 27 residents living at the home. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A range of written records were also examined. Residents were spoken with both individually and in small groups and five of these service users’ records were examined. Discussions were held with Mrs. Mackenzie-Rollinson registered manager and one Director of the company which owns and operates the home. Three staff were spoken with individually and a discussion with regular visitor to the home formed part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: There is no formal system in place for the supervision of staff. This was a requirement made at the last inspection in March 2005 and has been repeated as a result of this inspection with a revised timescale for this to be implemented. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 6 The home’s fire alarm system was completely renewed recently. There was one fire door held open when the inspection first started. Because this fire door is close to the kitchen and discussion with staff confirmed that the door needs to be open to allow staff to use it throughout the day the report requires that it is not held open and an alternative safe way of holding it open is found. 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 The DS0000007741.V271158.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 Hall The DS0000007741.V271158.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): 3. Standard 6 does not apply. Prospective residents are provided with information about the home which includes the services and facilities offered by the home and how their needs would be met. Details of needs are gathered and recorded prior to any person being admitted to the home so that they can be assured these can be met. EVIDENCE: Five service users’ records were examined, one of which related to a recently admitted resident. These showed that an assessment of individual needs is made and recorded prior to people being admitted to the home. These showed a balanced assessment highlighting both abilities and needs, and how these were to be addressed. Where prospective residents have been referred by a local authority care manager, their assessment is used as the basis for care to be provided. Records showed there are opportunities for service users to be as independent in daily living as they wish, and likes were seen noted on files examined, as were risks associated with manual handling or challenging behaviour. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 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 The health and personal care needs of service users are recognised and recorded so that service users can be sure that they are being looked after. EVIDENCE: Five care records were examined, one without a fully developed care plan. This record was for a resident who had been admitted most recently to the home. In each instance, a monthly review of assessed care needs was recorded and any change to the care plan made. Identified health care needs and conditions which required particular care to be given were recorded. Care staff were heard assisting residents in their own rooms talking to residents with respect when providing care. Domestic and kitchen staff assist with service of breakfast and hot drinks. Service users confirmed that staff were kind and helpful and that they were able to make choices about the way they spend their day. A medication policy and procedure is in place which protects residents. The home uses a monitored dosage system which was examined. Records detailing the medication time and dosage were seen and were up to date. Storage and disposal of medication was seen and was satisfactory. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 10 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 Daily life and social activities offer service users opportunities to live their preferred lifestyle and retain relationships in the wider community EVIDENCE: Several service users were spoken with in small groups. They said that they were able to choose their daily routines and did not feel that they were obliged to do anything if they didn’t wish to. A regular visitor to the home was spoken with who commented that staff employed at the home showed a real affection for his relative who responded to this. Several residents said that they were able to have a meal in the public bar attached to the care home at any time and some did this at times when they had visitors. The dining room is a spacious and pleasant place in which to eat meals. Service users spoken with over lunchtime said that they could choose to eat meals in their room if they wished. They commented that there was a choice of an alternative if they did not like the offered menu. The food served was presented well and service users said that the meals at the home were of a very good standard. Some service users spoken with said that they did not always have enough to do to pass their time but had bingo occasionally, organised by the home. However, two of these residents organised between them to play scrabble, and Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 11 during the inspection, a small group of villagers came into the home to play scrabble, which residents said was a regular event. One resident said that he took a walk every day around the village and was very articulate in saying how much he enjoyed meeting other people in the village and talking to them. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Service users are able to make a complaint using information provided by the home. Service users are protected by the awareness of staff of potential abuse. EVIDENCE: A complaints policy and procedure is in place and was examined. People resident at the home are given information on how to complain in the Service User Guide to the home. The procedure includes timescales for investigation and response to any complaint made. Service users spoken with said they had had no occasion to make a complaint, but would speak initially to the registered manager. The complaints record was examined: there had been no complaint since the last inspection. A discussion was held with three care staff on an individual basis. Staff showed an awareness of the different forms of abuse and were clear what they would do if they saw or suspected an abuse. The registered manager has access to the local authority’s protocol on the protection off vulnerable adults. The system for handling service users’ money was seen and was satisfactory. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26 The people using this service live in a clean and well maintained environment. EVIDENCE: A number of bedrooms, bathrooms and communal areas of the home were seen. All areas were decorated and furnished in keeping with the overall style of the building and it’s layout enables service users choose to have company or not. Those parts of the premises seen were uniformly warm and free from unpleasant odours. Domestic staff are employed to maintain cleanliness and hygiene standards. Those service users and visitors spoken with confirmed that this standard of cleanliness is the norm. Service users said that their laundry is dealt with and returned to their room and that their bedding is changed on a regular basis. All sheets and towels are hired and laundered by Ryedale laundry. The home employs a laundry assistant for ironing and help with any alterations or mending. Policies and procedures were seen for the control of infection. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 14 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 and 30 Staffing levels and their skills mix are at a sufficient level to ensure the needs of service users are met. Recruitment and selection procedures ensure that people who are unsuitable to work with vulnerable adults are not employed, though attention needs to be given to transferring employed people to care worker posts. EVIDENCE: Four care workers’ records were examined. These showed that two written references and a criminal records disclosures had been sought. However, in one instance where a member of care staff had transferred from kitchen duties, written references had not been obtained. Care staff are given the GSCC Code of Conduct when newly appointed. Following discussion with the registered manager, this document will be given to all care staff. Two completed rotas were given to the inspector which were later analysed. These showed that the number of care staff employed during the day are no fewer than four each morning, with three staff on duty each afternoon and evening. In addition to care staff, three domestic staff, a laundry person, a secretary and a gardener/handyman are employed. The registered manager does not under normal circumstances provide direct care. The rotas showed that the numbers of care staff deployed to deal with the assessed needs of service users was satisfactory. Of the nineteen care staff at the home, seven have an NVQ qualification in care level 2, and three have an NVQ qualification in care to Level 3. A further three care staff are working towards the NVQ 2 qualification in care. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 15 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 People using the service can be assured that their needs will be met by staff who are trained and competent in providing their care and who receive informal supervision, though a system for formal supervision of staff and for quality assurance would ensure this. The health, safety and welfare of service users is addressed by the arrangements to ensure the building and its systems are maintained in a safe manner, though attention is needed to ensure fire doors are not held open. EVIDENCE: Mrs. Johanna Mackenzie-Rollinson is the registered manager of the home. She is a qualified state registered nurse and maintains her registration. She is currently undertaking the Registered Manager’s Award. A number of documents were seen relating to the arrangements at the home to ensure that the building and systems in place comply with health and safety legislation. These were:Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 16 • • • • • Fire Department visit dated 15/2/05 Gas Safety Certificate dated 18/4/05 Electrical Installation Certificate dated 17/10/01 (valid for five years) Checks on the passenger lift and stair lift dated 6/10/05 Fire fighting equipment, emergency lighting and fire detection check dated 12/7/05 One fire door was being held open at the start of the inspection and this was discussed with the gardener/handyman on duty. He explained that the system to ensure fire safety precautions and the alarm system had been renewed in recent years. This included a number of automatic closers on doors linked to the fire detection system being installed to allow passage of service users and staff. The door in question near to the kitchen had not been fitted with an automatic closer at that time and remained closed throughout the rest of the inspection. It was not clear whether this door had been missed when the assessment for automatic closers had been made. The accident record was examined. This held personal information in a collective way. The registered manager said that the record of individual accidents would be filed in individual files. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 17 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 X 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 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 1 X 1 Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Schedule 2 24 Requirement Two written references must be obtained for potential care workers prior to their appointment. A quality assurance system based on service users’ views should be developed and implemented. This was a requirement made still outstanding from the last inspection. A system for the formal supervision of care staff must be developed and implemented. This was a requirement made still outstanding from the last inspection. Fire doors must not be held open. The fire door identified should be assessed for fire risk. Advice should be sought from the fire authority. Timescale for action 31/01/06 2 OP33 31/01/06 3 OP36 18(2) 31/01/06 4 OP38 23(4) 31/01/06 Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 19 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 OP38 Good Practice Recommendations Accident records should be maintained in a way which protects personal information and complies with data protection legislation. Hall The DS0000007741.V271158.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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