Inspection on 27/07/05 for Hallcroft Care Home

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Hallcroft Care Home 09/12/08

Hallcroft Care Home 22/08/06

Hallcroft Care Home 05/01/05

Hallcroft Care Home 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Hallcroft Care Home Croft Avenue Hucknall Nottingham NG15 7JD Lead Inspector Jayne Hilton Unannounced 27 July 2005, 10.00am 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. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hallcroft Care Home Address Croft Avenue Hucknall Nottingham NG15 7JD 0115 9680900 01159632388 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) Tamaris Healthcare (England) Ltd Acting Manager Josephine Greeveson Care Home with Nursing 40 Category(ies) of 37 - Old Age registration, with number 3 - Terminally Ill of places Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5/10/05 Brief Description of the Service: Hallcroft is a purpose built home, set in a residential area of Hucknall, Nottinghamshire. Hallcroft has forty beds with Nursing care being provided in the home. There are 36 single rooms and 2 double rooms, which all have ensuite facilities. In addition there are 7 WC’s 5 bathrooms, one with a parker bath and 1 shower. A passenger lift provides access to both floors. A pleasant garden area is provided. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken on Wednesday 27th July 2005 at 10am and was unannounced. The inspector was Jayne Hilton. The focus of the inspection was mainly to review the requirements set at the previous inspection. The methodology used was examination of three care plans and associated documentation, including social activities records, complaints records, quality monitoring records, staff personal files, including training records and induction. Two service users were spoken with in detail and others were spoken with throughout the inspection. Three staff members, the manager and the administrator participated in the inspection process. A tour of the building was incorporated into the inspection and included two service users rooms. The inspection was completed in three and a half hours. What the service does well: The home is assessed as well managed and run in the best interests of service users as record keeping practices are excellent, the manager and administrator has provided many systems, which exceed the requirements of the standards. Prospective and existing service users have the information, terms and conditions to make an informed choice about where and how they live with their needs being fully assessed and met. Service users confirmed that their health, personal and social care needs are fully met and that they are treated with respect at all times. Service user outcomes are excellent and the staff team praised by service users and by the inspector for their dedication and commitment to the promotion of, a quality lifestyle for service users. The service users expectations, preferences, social, cultural, religious and recreational interests and needs are met and exceed the standard also. Service users are happy with the food provided and their nutritional needs are well addressed. They are aware of the complaints procedure and confident that they would be dealt with appropriately, are protected by good policies and procedures in general and state that they feel safe. Service users live in a clean and well - maintained environment with comfortable indoor and outdoor facilities, which are being further enhanced through a programme of refurbishment. Service users are supported by, a staff team, who are well trained. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 6 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. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 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 Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 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, 2, 3, 4 Prospective and existing service users have the information, terms and conditions to make an informed choice about where and how they live. Service users needs are fully assessed and report that their needs are met fully. EVIDENCE: There is a comprehensive statement of purpose in place in large print. Service users have a copy of the service user guide in their rooms. The terms and conditions document has been completed. Because of implications with the home previously being in receivership the document had been delayed as has been with the Officer of Fair Trading for ratification. The process was reported to be finalised by the end of the week of the inspection. Four Seasons Healthcare has produced a comprehensive assessment document, which includes waterlow, dependency and social, nutritional continence, wound care, manual handling. Cognitive skills assessments are included in the package. The assessment is based on Ropers Activities of daily living and also covers stability and unpredictability. The assessment addresses preferences and monthly reviews. The home appears to meet the needs of current service users. Service users and spoken with reported that the staff treated service users well and they were happy with the care. Training appears to be provided to a satisfactory standard. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 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, 8,10 Service users confirmed that their health, personal and social care needs are fully met and that they are treated with respect at all times. Service user outcomes are excellent, and the staff team is praised by service users and the inspector for their dedication and commitment to the promotion of a quality lifestyle for service users. EVIDENCE: Three service users care plans were examined and found to be satisfactory. Care plans were detailed, reviewed monthly and daily reports a good reflection of the service users daily needs and progress. Communication systems have been improved by the introduction of a communications book, which is made available to all staff. Care plans were signed unless relatives had not responded to requests to be involved. The manager reported that she would consider further attempts to include relatives’ co-operation in these cases. Service users spoken with were very aware of their care plans and reported that they had been involved in the review of these. Reviews are carried monthly or more frequently as individual needs change. A robust system is now in place to ensure that where the manager is not available such as holiday periods that care plans are not overlooked for newly admitted service users at this time. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 10 The care plans were observed to reflect the assessed needs of service users. The healthcare needs of service users appeared to be fairly well met and record sheets were in place for GP visits, dental, chiropody, optical and physiotherapy input. Nursing interventions appeared to be well documented. Falls were well monitored by use of risk assessments and incident monitoring. Service users nutritional needs are risk assessed and monitored daily by a system of communication for both care staff and kitchen staff. A physically disabled service user reported that her skin was intact and that staff check her routinely for pressure areas and that continence was well managed. Allergies are clearly identified on care plans. Service users reported that their privacy and dignity is respected at all times and staff, knock before entering rooms. There is a mobile telephone available for service users, although some do have their own telephones. A service user confirmed that mail was given unopened and that any personal information, would be treated confidentially by staff. Comments by service users included “ staff are great but run off their feet” “the call alarm is answered promptly within minutes” I am perfectly happy with everything” “my needs are most definitely met” “I have everything I need” “ staff treat me with kindness” “ I feel sorry for the staff sometimes, not everyone appreciates them” “ if it wasn’t for the staff I would be insane as they keep me going with a laugh and a joke” Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 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, 15 The service users expectations, preferences, social, cultural, religious and recreational interests and needs are met and exceed the standard. Service users are happy with the food provided and their nutritional needs are well addressed. EVIDENCE: The activities co-ordinator is currently not working due to sickness so the provision of activities is reduced at the moment. Staff are endeavouring to keep some activities going such as bingo. A formal programme has been devised and staff have provided extra outings/events for example one service user who is a Hucknall Town supporter was able to meet the players before their round in the final of The Football Association Trophy. The staff member arranged for and escorted the service user to the team’s home ground where the players presented him with a scarf and rosette and posed for photographs. It was reported also that two service users had been assisted to achieve a trip into town, which they had not been able to do for some time. Forthcoming events are posted for Famous Faces; sing alongs with various entertainers and a boat trip on the river Trent. Special hand made cards can be purchased by order and proceeds go to the resident fund. There has also been a live Owl presentation. Social assessments are in place and there is documentation regarding participation by service users. There are plans to develop the garden area for service users to use for growing plants and a possible sensory Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 12 garden. A service user made comment that service users have many varying needs and that activities are not always well supported. A newsletter is issued monthly. The staff team have clearly worked at improving the social and leisure facilities at the home and commended for the achievements in this standard. Service users spoken with confirmed they had a full choice about their daily lifestyles, including bathing times, going to bed and getting up. Menu choices are offered. A service user praised the staff, adding that she was glad to be living in the home and wished to spend her remaining years there. The lunchtime meal was observed and evidence was seen of service user choice of menus. Staff were observed to be wearing appropriate protective clothing and were noted to assist those who needed it sensitively and professionally. Adapted cutlery was observed to be in place for those service users who required them. Service users reported that the food was good. On a recent service user survey the result for food provision out of seventeen responses were: Excellent Presentation of meals Choice of meals 2 1 Good 6 5 Fair 4 5 Poor 1 1 Nil response 4 5 The menu choice on the day of the inspection was ham salad or gammon, potatoes and vegetables. Fruit sponge and custard, ice cream or yoghurt and diabetic sponge and custard. Serving arrangements have been reviewed so that each table is served at the same time and staff are allocated for serving service users who wish to remain in their rooms or who are ill in bed and for assisting those who require help with feeding. Drinks are provided as required throughout the day and service users confirmed staff would make a drink during the night if they requested one and reported that a drink is provided on waking. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 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 standard(s) 16,18 Service users are aware of the complaints procedure and confident that they would be dealt with appropriately. Service users are protected by good policies and procedures in general, however staff require updates in relation to this. EVIDENCE: The home has a complaints policy that meets the standards, Service users and staff clearly stated they would be confident that a complaint would be listened to if made. There were no complaints recorded at the home since the last inspection, neither had there been any received at CSCI about the home. Service users spoken with stated they had no reason to complain. The home has an abuse policy which makes reference to the Care Standards Act 2000 and the Public Interest Disclosure Act 1998. The home has a zero tolerance philosophy of abuse. The home has recently acquired the guidelines produced by Nottinghamshire Committee for the Protection of Vulnerable Adults. The home has a policy, which addresses aggression and control and restraint. The home has a gifts policy to protect the interests of service-users. Training in abuse awareness has been provided for all staff and there was evidence that the manager had covered the whistle-blowing policy in a staff meeting earlier in the year. When spoken with some staff did not appear fully aware of the policy for whistle blowing and the implications of this and it is recommended that staff have further input regarding its use. Staff were also not very aware of the General Social Care Councils Code of Conduct, despite this also being covered in detail in a staff meeting. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 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 standard(s) 19,20, 21, 26 Service users live in a clean and well - maintained environment with comfortable indoor and outdoor facilities, which are being further enhanced. EVIDENCE: The home is purpose built and is generally well maintained with a handyman on site. The home is homely in appearance and there is evidence of maintenance and renewal since the last inspection. The gardens are neat and well maintained allowing access to service users via ramps and steps, there is a patio area and gazebo. The carpeting in the hallways and reception areas look shabby, despite cleaning and the replacement of these would further enhance the homely appearance. The kitchen has been refurbished. A number of bedroom carpets have been replaced and a programme of redecoration is currently ongoing. Although there is a very large lounge, the seating is arranged into small groups. The dining area is very pleasant. An additional smoking lounge doubles as a craft room. All were assessed as spacious; appear comfortable, clean and smelled fresh. The décor, furniture and fittings are as domestic type Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 15 as possible and there were extra homely touches observed around the home. New dining furniture is planned in the near future. There are adequate bathroom and toilet facilities, which are personalised and appear to meet the needs of service users. The home provided currently 7 WC’s, 5 bathrooms [1 with Parker bath] and 1 shower. In addition all rooms have en-suite facilities. The bathrooms and toilets examined were clean and smelled fresh. Rooms of those service users case tracked were well equipped. Service users and relatives are asked to inform the home if the room does not meet with their requirements. Evidence of this was seen in service users rooms. Lockable facilities were evident in the room but not all doors had locking facilities. The acting manager is currently undertaking a survey with service users and locks are to be fitted where service users request this. The manager reported that the work for some door locks has been put on hold, as there is discussion currently regarding health and safety implications. The home appeared clean and all those rooms of that case tracked smelled clean and fresh. A service user commented that the home is always spotless. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 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 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) 29, 30 Service users are supported by, a staff team, who are well trained and employed by, strict recruitment policies, however current guidance was not being followed and therefore needs to be implemented. EVIDENCE: The personal files of a sample of three staff were examined and found to be not totally satisfactory. POVA first checks [Protection of Vulnerable adults] had been carried out but Criminal records disclosure checks had not been obtained prior to the staff member starting work. It appeared that this was due to the new updated guidance not being obtained by the provider rather than by intent. However a requirement is set for this. The manager was committed to ensuring this would be implemented immediately and in conjunction with the provider updating their policy and practices. A training programme is in place and this was examined. Staff appear to receive a good level of training and confirmed they had undertaken training in manual handling, dementia care, first aid, fire awareness, food hygiene, food awareness, abuse awareness and NVQ 2. Four Seasons Health care are currently operating a staff training and development programme, which meets National workforce training targets. They have a dedicated training manager and a new training manual to include all mandatory training and induction. There is a fast track section for experienced carers. Twelve week courses are provided for infection control, basic care practice, open learning and study packs are also available. Four Seasons Healthcare pays for all training days. Existing staff undertake refresher training to bring them up to date with current induction topics. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 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) 33,37 The home is well managed and run in the best interests of service users. Record keeping practices are excellent and the manager has provided many systems, which exceed the requirements of the standards. EVIDENCE: Four seasons Healthcare carry out audits and monitoring of the home. There was evidence of service user surveys and feedback is posted on the notice board. Service users meetings have been recommenced and reported to be going well. Evidence of staff meeting minutes was seen. Regulation 26 reports and regulation 37’s are submitted as required by regulation. The manager has implemented many systems since she moved to the home in the last eight months and all records examined were up to date. The administrator is praised also for her assistance with this. Care plans and other personal information about service users is stored securely. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 18 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 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x 4 x Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 19 No Are there any outstanding requirements from the last inspection? 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 7,9,19 Requirement New staff must not be allowed to commence work without a current Pova first check, a satisfactory criminal records disclosure and two satisfactory references Timescale for action 27/7/05 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. Refer to Standard OP18 OP19 Good Practice Recommendations Update for staff should be undertaken once again in adult protection policies and the GSCC code of conduct. The carpets in the hallways and reception areas should be replaced. Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle road Nottingham, NG2 1RT 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 Hallcroft Care Home C03 C53 Hallcroft S57801 V235592 270705 Stage 4.doc Version 1.40 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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