Inspection on 07/11/06 for Hall The

This inspection was carried out on 7th November 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 The 02/03/06

Hall The 06/12/05

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 Karen Ritson Key Unannounced Inspection 7th November 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 The DS0000007741.V319099.R01.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 The DS0000007741.V319099.R01.S.doc Version 5.2 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.V319099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 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. The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. The charges range between £340 and £695 per week. The higher charge is for an apartment to be occupied by two people. Chiropody, hairdressing, toiletries and newspapers are not included in this fee and these are charged at cost. This information was provided to CSCI on 18/08/06. Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection for this service took 12 hours. This includes time spent gathering information and examining documentation before and after a site visit and in writing the report. The site visit took place on 7th November 2006 between 9:30am and 3:30pm. Information for this inspection was gathered from the following: • A tour of the premises • Observations of care throughout the day of the site visit. • Speaking with service users. • Speaking with staff. • Case tracking three service users on the day of the site visit. • Looking at information provided by the manager in a pre inspection questionnaire. • Notifications sent to the commission from the home since the last inspection. • Examining policies, procedures and records kept at the home, including staff files. • Examining information regarding the home on the file kept by CSCI. All key standards were looked at during this inspection. The manager was present throughout the day of the site visit. What the service does well: This home offers a good service. Good care is offered in a well-kept and attractive setting. All service users, visitors and staff spoke very highly of the manager and felt she managed the home well whilst being approachable and understanding. The home is tastefully decorated and the grounds are very pleasant. Visitors are made welcome at anytime. One service user said the care: ‘Could not be better.’ The home writes down what care is required for each person and what needs to be done to avoid unnecessary risks. Staff also write down when doctors or other health care professionals call and make notes on any advice given. The staff are friendly and thoughtful and all have time to spend chatting or to help service users on a one to one basis. One service user said of the staff: ‘They have time to talk and I feel they have got to know me well.’ Another said: Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 6 ‘They are so kind, they really couldn’t do any more.’ The meals are of a particularly high standard. One service user said: ‘The meals are first class. We have a choice and are always asked what we prefer.’ The staff enjoy working at the home and there is a low turnover. Any complaints are listened to, acted upon and taken seriously. Service users are kept safe by good health and safety procedures and thorough staff training. 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. The summary of this inspection report can be made available in other formats on request. Hall The DS0000007741.V319099.R01.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 The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. (6 is not applicable.) Quality in this outcome area is good. Prospective residents and their representatives have the information needed to choose a home. Service users needs are assessed and a care plan is drawn up from this. This ensures their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users receive a thorough assessment of care needs before admission. This includes risk assessments where relevant. The home completes a personal history for each service user, and a description of each person’s likes, dislikes and interests is included. One service user said: ‘I was made to feel very welcome. (The manager) spent a great of time asking me about what I needed and how they could best help. I really felt she was getting to know me as a person.’ Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 9 Observations of care showed that service users needs were well known to staff. The manager and staff said service users and their relatives are encouraged to look around the home before admission and the home provides a statement of purpose and service user guide to help people make a decision. The home does not usually offer intermediate care. Hall The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The health and personal care a resident receives is based on individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are detailed and often reviewed. Risk assessments are included when necessary. All visits from health care professionals are recorded. The home is good at monitoring the day to day health of each service user, daliy notes contain appropriate and useful information. One service user said: ‘They know what I need and they’re very good. They will get the doctor straight away if there’s a problem.’’ Observations of care showed that service users are treated kindly with their privacy and dignity respected. Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 11 One service user commented that the staff always addressed her by her surname, which was what she preferred and always rang the doorbell of her flat before coming in. She liked this. Medication is kept, given and recorded appropriately, with policies in place. Staff who handle medication have had training. Some of the service users handle their own medication. A policy on self -medication is needed and a risk assessment needs to be in place for each service user who self medicates., otherwise there is the potential of service user being at risk. Observations of care showed that service users are treated kindly with their privacy and dignity respected. Hall The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Service users are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Service users receive a healthy, varied diet, which they enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many of the service users are reasonably independent and pursue their own social and leisure activities. A scrabble club and bridge club meet at the home each week and service users are invited to join in should they so wish. Some of the service users enjoy gardening and several have cultivated individual plots within the grounds and attend to cuttings etc in the greenhouse. Several service users have window boxes and tubs. Darts and dominoes are available in the bar, which adjoins the home. The home has a library and books are also available through the visiting library van. A minibus is hired in the summer months for outings and there is a plan to purchase a minibus to allow for more spontaneous arrangements in future. Service users said they had plenty to do and were able to choose activities, which reflected their preferred lifestyle. Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 13 The meals are very good. There is a choice at each meal and service users may also choose from the bar menu should they wish. One visitor wrote that whilst he was at the home, ‘A member of staff came in to obtain the choice of meal.’ He went on to say that his friends commended the standard of meals. One service user said: ‘The food is just lovely. I’m putting weight on it’s so nice.’ The staff pay great attention to the likes and dislikes of service users regarding food. Detailed lists were seen of how each person liked their tea or coffee, whether they preferred a biscuit and what kind. Any details regarding special diets are recorded carefully. A midday meal was sampled and was of a very high standard. All service users said the meals were very good. Several commented they were first class. Hall The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents have access to an effective complaints procedure; their complaints are listened to and acted on. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. Service users said they could speak with staff if there was a problem or they had a complaint and that they were confident they would be listened to and any concerns acted upon. They said that the manager visited them often in their rooms and encouraged them to tell him if there were any problems or niggles. All complaints are recorded with outcomes. Staff have received abuse awareness training. The home has an equal opportunities policy and procedure. Service users said they felt well cared for in the home, none said they had ever had cause to complain or had ever felt unsafe. Hall The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in a safe, well-maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well decorated and homely. There is ample communal space and most rooms look out over the attractive grounds. Rooms are decorated to their taste. One service user said: ‘I have a lovely balcony and the grounds are beautiful particularly at this time of year. The sun just streams in.’ Another said: ‘I couldn’t fault the room. It’s very comfortable with everything I need.’ Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 16 Many rooms were personalised with pictures, photographs and items of service users own furniture. The recommendations of the latest fire authority visit are being implemented. The laundry is situated away from the kitchen and meets the standard. All sheets are hired and laundered away form the home. Service users said they had no problems with their laundry. Hall The DS0000007741.V319099.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. Staff in the home are trained and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well staffed with little staff turnover. There are four members of staff on duty during the mornings, three in the afternoons and two at night. Over 50 of staff have NVQ level 2. Staff files are well organised and contain all relevant information. The home recruits staff well and now uses an umbrella body for CRB checks, any previous irregularities have been remedied. Information provided on the pre inspection questionnaire confirmed that staff received induction and foundation training to TOPSS guidelines. This was confirmed during the site visit. Service users said they felt confident staff knew what they were doing and that they understood their particular needs. Staff said that the manager was very supportive regarding their training and that she was always there to offer encouragement. Hall The DS0000007741.V319099.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 36 and 38. Quality in this outcome area is good. Service users benefit from an open style of management based on respect and from the considerable experience of the manager. Service users views inform practice. Service users welfare is protected by good health and safety systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is in the process of completing the Registered Managers award. She already holds the equivalent to NVQ 4 in care, as she is a registered nurse. All staff commented on how supportive and approachable she was and how they now had formal supervision with her in addition to being encouraged to address any issues with her on a day to day basis. Service users also Hall The DS0000007741.V319099.R01.S.doc Version 5.2 Page 19 commented on how approachable and kind the manager was. She has worked hard to improve the quality assurance system. This is now comprehensive. The views of service users and others have been canvassed and the responses collated. The manager also carries out her own annual audit based around the outcome groups of the national minimum standards and incorporates this and survey results into an annual plan for the improvement of the service. All policies and procedures have been reviewed this year. The development of the quality assurance system ensures that the care offered is informed by those who use the service. All maintenance certificates examined were up to date. The electrical wiring safety certificate was due for renewal. Policies and procedures in safety including environmental risk assessments have been updated this year. This ensures the safety of service users. Hall The DS0000007741.V319099.R01.S.doc Version 5.2 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 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 4 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Hall The DS0000007741.V319099.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action 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 OP9 2 OP31 Refer to Standard Good Practice Recommendations A risk assessment for those service users who self medicate is required. The manager is reminded of the current requirement to be qualified to NVQ level 4 in management. 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