Inspection on 10/08/05 for The Hallewell

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

The Hallewell 06/01/07

The Hallewell 09/01/06

The Hallewell 27/01/05

The Hallewell 14/07/04

The Hallewell 16/02/04

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

CARE HOMES FOR OLDER PEOPLE Hallewell, The 20 Hallewell Road Edgbaston Birmingham B16 0LR Lead Inspector Susan Scully Announced 10 August 2005 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. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hallewell, The Address 20 Hallewell Road Edgbaston Birmingham B16 0LR 0121 454 9862 0121 454 6932 N/A Mrs Gwen Billing 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) Mrs Marcella Marie Higgins Care Home 3 Category(ies) of Care Home registration, with number of places Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27 January 2005 Brief Description of the Service: The Hallewell is a three story Victorian premises located in a residential area of Edgbaston Birmingham. The home is close to Birmingham City Centre and has easy access to local amenities including a park, shops and public transport. The home offers care to three elderly people with a mental health disorder and is also the home of the owners. The Hallewell comprises of a large kitchen and combined dining room, two lounges, a conservatory, a small laundry area and a toilet and bathroom on the ground floor. On the first floor there are three bedrooms, one single and two doubles (one of which is for the use of the owners ), a toilet and bathroom. The top floor is used for storage purposes. There is a well maintained garden to the rear of the home which service users are free to use. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report is based on information received from the Manager and Deputy Manager. Unfortunately the residents are uncomfortable speaking to people they don’t know so the report is based on what the manager and Deputy/Owner said. The observations made during the visit and sampling of records held in the home. Only two comment cards sent out by the Commission before inspection was returned. Theses gave no indication of what it was like to live in the home. 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. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 standard(s) 3, Resident’s needs are assessed in conjunction with the Local Authority and advocates when required. EVIDENCE: The residents have been at the home for a number of years. Information obtained at the initial assessment was seen. The manager said residents were part of the family. The home is run as a family unit where residents are consulted on a daily basis regarding their preference with food activities and daily needs. The residents have limited communication skills and will not talk to anyone they are UN familiar with. However, residents were well presented and interaction between the manager and deputy was positive. The residents had visited the home before admission. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 8 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, 9 The Health and Welfare of residents are monitored and recorded to ensue the Health Care needs are met. Daily records do not reflect what is done for residents on a daily basis or activities they participate in. Medication records are not sufficiently complete to enable an audit of medication. Professional advice must be sought on a regular basis to prevent any mistakes. EVIDENCE: The resident’s needs had remained fairly static since admission. The Deputy Manager/Owner demonstrated her knowledge concerning resident’s needs likes dislikes, and how residents were consulted about their care. Residents observed throughout the day were able to move freely around the home and were given choice and flexibility concerning meals and activities. Care plans gave information pertaining to health needs, consultation with GPs and other health professionals. The Deputy Manager said “all three residents do what they want to do they are part of the family we will support them’’, “ the aims of Hallewell is to provide a stable and secure homely environment for residents to live Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 9 independently with support and guidance to show respect and maintain their dignity’’. In daily records, the recording of information of the resident’s daily lives was poor; although it was evident, the needs of residents were being met. The recording of information must improve to give a reflection that all aspects of the assessed needs of residents are being met. The Deputy manager said “because residents are part of the family it is not always recorded what residents do on a daily basis and tends to be Doctors Appointments and Health Care needs that is required that is recorded, and not always were they have been or what they have done because its just taken for granted that residents are part of the family and treated as such’’. The inspector observed the positive interaction with residents and although the residents did not speak to the inspector observation showed that the resident’s had confidences in the Deputy Manager. However daily records must be maintained. Medication records were not completed satisfactory. Advice was given during the inspection it is a requirement that the manager seek professional advice immediately. The inspector has asked the pharmacy inspector to visit the home to give guidance and support. The deputy/owner would contact the local pharmacy for advice in the interim period. The inspector completed an audit of medication and this showed Risperidone 2mg, with a balance of 34, with 19 dispensed, should have left, 15 tablets, there were only three in the building. Larazepam balance brought forward 41, dispensed 28 should have left 13, there were only 12 tablets in the building. When the inspector and owner/ deputy checked it transpired the balance bought forward was incorrect. Immediate action was taken on the day of the visit to rectify the inaccuracies. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 standard(s) 12, 15 All residents participate in activities according to their choice. The residents receive a well planned and balance diet that is of good quality cooking. EVIDENCE: The deputy manager /owner said “Residents lead an activities lifestyle, going to dances clubs, and day centre’’. “Each week residents chose to go dancing, this also enables residents to maintain physical activities. “Shopping is a weekly occurrence where residents assist in shopping for the weeks food and have a choice in what they wood like’’. The Manager does not keep daily activities plans for each resident and residents did not confirm what activities they do. It is therefore a requirement for daily activities to be recorded. Residents will not speak to people they don’t know and it is for this reason that information, confirmation be available for inspection. The deputy manager/owner said “It is very important for residents to make their own decisions with support to maintain independence’’ and assured the Inspector this is what residents do. Recorded in care plans are goals the residents what to achieve and documentation to the latter was recorded. The inspector observed the positive interaction with residents and although the residents did not speak to the inspector observation showed that the resident’s Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 11 had confidences in the Deputy Manager/ Owner. However daily records must be maintained. The Inspector sampled the lunchtime meal, which consisted of braised lamb, green vegetables and potatoes. The meal was excellent. Both residents eat all the meal including spotted dick with custard. Residents choose on a daily basis what they would like to eat. All meals consumed are recorded to ensure a varied and well balanced diet is provided. The husband of the owner of the home is the cook. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Each resident is given a copy of the complaints procedure with information of who to complain to and the time scale of response. The Adult Protection policy and procedure must be available for inspection. EVIDENCE: A comprehensive complaints procedure is given to all residents, that shows the time scale in which complaints will be responded to. The home had had no complaints since the last inspection. The Deputy manager /owner said “complaints do not normally happen because discussion are held regular on a daily basis to see if residents have any concerns or worries and these dealt with promptly if there is a problem’’. At the time of the visit, the adult protection procedure was not available. It was recommended that the manager obtain a copy of the Birmingham Agency Guideline in Adult Protection and the Department of Health no Secrets. Although there have been no accidents since the last inspection the accident book did not comply with Data Protection. The manager must notify the Commission of all occurrence that effect the welfare and the well being of the residents on the appropriate format regulation 37 of the National Minimum Standards. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The home is clean well maintained and suitable for its stated purpose. EVIDENCE: The location and layout of the home were suitable for its stated purpose. The home is also the family home of the owner and provides a very comfortable and clean environment. Furnishing and fitting is of a good standard and residents bedroom were decorated in the residents choice. The one bathroom on the upper floor requires decoration where the ceiling paint is coming off. The home would not be suitable for anyone with physical disabilities as aids and adaptations were limited. There is a very pleasant garden to the rear of the property leading off from a large conservatory. There had been no change to the communal space since the last inspection and remained comfortable with ample space of two lounges and a large kitchen with a good dining area. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The Manager, owner/deputy have the relevant skills and competences to meet the needs of the residents. EVIDENCE: The management has changed since the last inspection. The owner is now the Deputy Manager. The Manger from number 22 has recently been registered to take responsibility for number 20. No other staffs are employed at the home. The Deputy Manager /Owner’s husband is the cook and on occasions gets involved with the residents daily lives. An enhanced police check for Mr Billing was required at the last inspection and this has been completed. Help is also at hand if required from a registered nurse who knows the residents very well and this has been the arrangements for a number of years and works well. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 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) 31, 33, 38 The residents live in a home from home environment that is well run and in the best interest of the residents. The Health and Safety of residents is maintained to a satisfactory Standard slight improvements must be made to ensure full compliance with this standard. EVIDENCE: The manager and deputy demonstrated their knowledge regarding the resident’s needs, likes, dislikes, and they were aware of the history, preference and what resident’s main aims and objectives were. The Deputy said “ looking after the residents was like looking after her own family, and to be able to understand you would have to live at the home to know’’. The Inspector was in no doubt that the manager and deputy was able to care for the residents and seek professional help is needed. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 16 The Manager completes risk assessments for all aspects of the home and residents. These are regularly reviewed. For example, risk assessments are completed for Fire Safety, the Premises, Food Hygiene, and residents going out. Not all hot water outlets are regulated and this must be completed for all showers and sinks that the residents use. Temperature checks must to be completed on all hot water outlets to take action and prevent scalding if required. Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 3 x 3 x x x x 2 Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 18 Yes 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 8 Regulation Requirement Timescale for action 1 September 2005 1 September 2005 1 September 2005 2. 9 3. 9 4. 18 5. 38 14(2)(a,b) Daily records must reflect the residents activities each day and be auditable to ensure residents needs are being met in line with their assessed needs. 13(2) All Medication must be signed for as administered at the time of administration. (Previous time scale 15/7/04 Non Compliance) 13(2) Any balance of medication held in the home at the end of monthly MAR charts must be carried forward to the new MAR chart to ensure there is a complete audit trail. (Previous time scale 21/7/04 Non Compliance. 13(4)(c) Policies and procedure for the protection of the residents must be available for inspection. An Accident book must be purchased that complies with Data Protection. 13(4)(c) All water outlets must be regulated. All water outlets must have a water temperature check completed on a regular basis to prevent scalding. 1 September 2005 1 October 2005 Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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 Good Practice Recommendations Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Hallewell, The E54 S17048 Hallewell The V227689 100805 Stage 4.doc Version 1.30 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. 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