Inspection on 11/10/05 for Hallamshire Residential Home

This inspection was carried out on 11th October 2005.

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

Other inspections for this house

Hallamshire Residential Home 23/04/08

Hallamshire Residential Home 10/05/06

Hallamshire Residential Home 30/11/04

Hallamshire Residential Home 24/06/04

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

CARE HOMES FOR OLDER PEOPLE Hallamshire Residential Home 3 Broomhall Road Sheffield South Yorkshire S10 2DN Lead Inspector Shirley Samuels Unannounced Inspection 11th October 2005 08:40 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 Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hallamshire Residential Home Address 3 Broomhall Road Sheffield South Yorkshire S10 2DN 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) 0114 266 9669 0114 266 9669 None Hallamshire Old People`s Residential Home Limited Ms Beverley Jane Ward Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (32) Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 32 beds 10 can be used for dementia elderly (DE/E) or mental disorder elderly (MD/E) Three beds may be used for service users under the age of 65 but not less than 60 years of age. 13th June 2005 Date of last inspection Brief Description of the Service: The care home provides care to 32 people (10) of the places are for older people with dementia or mental health problems. The home is situated in the Broomhall area of Sheffied. Accommodation is provided on three floors. There are 4 lounge areas one of which is used mainly for activities. There are three dining areas one that is seperate while the other two are integrated into the lounge areas. The home is surrounded by a mature garden which can be enjoyed by the service users and is near to local shops and accessible bus route. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over four and a half hours. Six service users, four members of staff, the manager and the responsible person were spoken to, and an inspection of the building was made. Observations were made of the interaction between staff and service users, the routines and the standard of care provided. What the service does well: 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. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 6 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 Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 7 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): 1,3 and 5 Service users were given the information they needed to make an informed choice. Prior to admission needs assessments were carried out and service users were assured that their needs would be met. Prospective service users and their relatives were able to visit the home to assess the quality of the facilities and the suitability of the home. EVIDENCE: Service users said they or there families were given written information about the home. Some said they were sure they were given information but could no remember the details. In each service user bedroom there was a copy of the complaints procedure and a service user guide detailing information about the home. This ensured that service users were able to make an informed choice and have accessible information. Records showed that assessments were carried out prior to admission. This ensured that the home had the information they needed to make an informed judgement about the service they were able to provide. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 8 Service users said they were able to visit the home prior to admission some said they had come for a meal and met some of the other service users. This gave potential service users and their families the opportunity to experience time in the home before making a decision. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Service users health, personal and social care needs are set out in an individual plan of care and their health care needs are fully met. In the main accurate records were kept of medication administered to service users. Service users do feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: A service user care plan was checked. This contained an individual plan of care, which detailed the needs of the service user the action to be taken by staff and details of the care provided. Service users said they knew the home kept records about them. Care plans did detail who had been consulted in the development of the care plan. This ensured that staff had written information detailing the needs of the service users. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 10 Service users and staff said regular appointments were made with health care professional eg dentist, opticians, chiropodist etc. This promoted service users health. Since the last inspection procedures had been put in place to monitor more closely the medication systems. The manager said she, along with another senior member of staff took responsibility for the weekly monitoring of the medication. Procedures were improved the manager added that where monitoring highlighted issues, these were addressed immediately action taken to rectify including, if necessary further training and guidance for staff. These procedures reduced the risk of errors and harm to service users. Service users said that staff treated them with dignity and respect. Staff were observed offering choice and encouraging service users to make choices. They were observed approaching service users in a respectful manner, speaking to them calmly and offering reassurance. Staff were able to verbalise the steps they took on a daily basis, to promote the rights of service users. They gave examples eg offering choice, privacy, explaining options, creating opportunity to take part in meaningful activity and spending time with service users getting to know them, their wishes and preferences. This ensured that service users felt they had control over their lives. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 In the main the lifestyle experienced by service users met with the expectation they had prior to moving into the home. Service users were satisfied with the social activities provided and were helped to exercise control over their lives. Service users received a wholesome appealing and balanced diet at times convenient to them. EVIDENCE: Service users said activities took place both inside and outside of the home. An activities coordinator was employed and attended the home for a few hours at least five days a week. A variety of activities were arranged to suite all needs and preferences. The staff said that time was spent on a one to one basis with those service users who chose not to join in group activities. Service users said that friends and family were able to visit and that they were made welcome. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 12 Service users said, “they feed us well” “the food offered is good” “ there is always a choice”. Staff said service users were, wherever possible consulted about the menu. Staff were observed offering a choice of cereals, porridge, fruit, fruit juices, tea coffee and toast for breakfast service users said they were able to have a cooked breakfast if the wished. Jugs of juice were placed in each of the lounge areas staff encouraged service users to drink plenty of fluids in-between meals. This ensured that service users were offered an appealing balanced diet and promoted their health and welfare. Since the last inspection a more dignified way of protecting service users clothing during mealtimes has been introduced, by providing cotton aprons instead of plastic. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not checked on this occasion EVIDENCE: Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 24 The fabric of the home was well maintained the interior decoration carpets and furnishings were in poor condition. Service users had bedrooms, which were safe and comfortable with their own possessions around them. EVIDENCE: Service users said they were happy with their bedrooms, these were personalised and well decorated. All the rooms were single. Some with en suite facilities. Service users said keys were provided and they were able to go to their room whenever they wished. This offered service users with comfortable personal space and freedom to access whenever they wished. There has been some maintainance of the building since the last inspection which included repair to the roof, new boiler, handrails plumbing and new water system. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 15 The décor, carpets and furnishings in the communal areas are in a poor state of repair. This has been an ongoing issue raised in the last few inspection reports. Some progress had been made since the last inspection and arrangements are in place for the décor furnishings and carpets to be brought up to the standard required. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Service users are not supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their job EVIDENCE: Service users said, “staff are very good at their job” “ I always feel safe” “there are always staff around”, “I just call if I need help”. Staff said there had been some changes in the way the staff were deployed and said “staff changes have had a positive outcome for the service users we have more time to spend with them now”. Staff said they received regular supervision and support on a daily basis. They added that regular staff meetings were held and that the staff team worked well together. NVQ training is ongoing at different levels depending on staff roles and responsibilities. This will ensure that staff receive training to the level required by the standards, resulting in a better service provision to service users. One staff file was checked this showed that the member of staff was employed and working in the home prior to a CRB being completed. This placed service users at potential unnecessary risk. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 17 The manager said since the last inspection staff had attended TOPPS induction training. First aid, adult protection, infection control and food hygiene were planned or being sought. The cook was not wearing the protective clothing provided and was observed wearing an outdoor hat and apron only. When approached she said she had forgotten her cooks hat and overall. The manager said this issue had been previously discussed with this particular member of staff. Issues remained which will need to be addressed and managed to ensure that hygiene standards are maintained. Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x x x 3 x x STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 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 3 4 4 Standard OP19 OP19 OP19 OP19 OP29 Regulation 16 16 23 13 19 Requirement The easy chairs in the lounge must be replaced. Previous timecale of 20/12/04 not met. Worn and threadbare carpets must be replaced. Pevious timescale of 20/12/04 not met. All areas of the home used by service users must be reasonably decorated. Sufficient bins must be provided for storing yellow bags containing clinical waste. All recruitment checks including CRB/POVA 1st check must be completed prior to employees starting work at the home. To reduce the risk of contamination of food, arrangements must be made to ensure kitchen staff wear the protective clothing provided. Timescale for action 20/01/06 20/01/06 20/01/06 20/11/05 20/11/05 5 OP30 16 20/11/05 Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hallamshire Residential Home DS0000002966.V254338.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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