Inspection on 06/01/07 for The Hallewell

This inspection was carried out on 6th January 2007.

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 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

The Hallewell 09/01/06

The Hallewell 10/08/05

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 West Midlands B16 0LR Lead Inspector Sean Devine Key Unannounced Inspection 6th January 2007 09:00 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 Hallewell, The DS0000017048.V323721.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. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hallewell, The Address 20 Hallewell Road Edgbaston Birmingham West Midlands B16 0LR 0121 454 9862 0121 454 6932 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) Mrs Gwen Billing Mrs Marcella Marie Higgins Care Home 3 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3) of places Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 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 DS0000017048.V323721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced at the weekend over one day to ensure the regulation inspector was able to meet with the services users. The home had prepared the pre inspection questionnaire, which was given to the inspector at the time of inspection. The inspector was able to meet with both service users, however due to their health conditions it was not always possible to gather their views and opinions of the service and quality at the care home. Both service users were case tracked, which included looking at their care, accommodation and opportunities. The inspector was able to meet the owner (who is the main carer), her husband (who cooks all meals) and the registered manager. There were discussion about how the needs of service users are planned, how they are met and the future of this small care home. What the service does well: What has improved since the last inspection? Since the last inspection the home has improved in some areas of how it is managing current stocks of medication and recording it. It has also checked that all water outlets used by service users had a thermostat to safely regulate the temperature and completed regular checks on water temperatures. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 6 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. Hallewell, The DS0000017048.V323721.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 Hallewell, The DS0000017048.V323721.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): Standards 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has in the past demonstrated that service users and their representatives are provided with information and opportunity to decide on whether the home can meet their needs and expectations. EVIDENCE: The admission policy was available. There had been no new admissions; there are currently two service users. The manager and owner were concerned that they had not had any recent appropriate referrals and asked why. This was discussed by them at some length due to the financial impact one vacancy has on the service. They are planning a way of marketing the service and also plan to liaise closely with social workers. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 9 Each service user was found to have a copy of the statement of purpose in their room. The home does provide an intermediate care service. Hallewell, The DS0000017048.V323721.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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that the health and personal care needs of service users can be met, improvements are needed to ensure that the needs and abilities, their choices and preferences are well planned for and that risks are identified and managed. If this is not completed and implemented the service users may be at risk of inappropriate care. EVIDENCE: The service users greeted the inspector but did not respond to any questions or join in conversation. They appeared very well cared for and healthy. The owner and her husband who support all the needs of service users described many of the care needs, risks and choices and it was clearly evident they had conviction to provide individual and person centred care. The registered manager also had a very good knowledge of the service users needs and was able to reflect on the day care service she provides. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 11 Both service users have care plans, these describe the area of need, how the need will be met, who will complete it and by when. It was found that the care plans were not specific and did not always describe the abilities of service users and what the owner and day services do. It was evident that both care plans were reviewed on a monthly basis, however they did not state whether the plan had been effective or otherwise. Other records of monthly meetings with service users were available often reflecting on a plan for the coming month and asking residents what they would like to do, records seen indicated one resident wanted to go out dancing, go out shopping and also go out for meals. Daily diaries confirmed that this was regularly achieved. Risk assessments for both service users were found to be brief. One service user had a risk assessment for a phobia and both had assessments about skin integrity using a Waterlow assessment tool. There were no risk assessments available for the risk of falls, moving and handling and no nutritional risk assessments. Both service users have not had risk assessments about what the care home must do should the mental health of residents begin to relapse, this was discussed with the owner and manager. The owner maintains good records of visits when service users visit primary and secondary healthcare services including GP, chiropody, medication reviews and hospital appointments. Service users also have appointments with a visiting optician. Medicines were found to be safely stored and stocks were found to be accurate. One service user has medicine administered at lunchtime at the day centre, these are signed for on a medication administration records (MAR) maintained at the day centre.; these medicines are given to the registered manager who operates the day centre and she signs when they have been administered. There is a concern that the owner of the home also signs to say she has administered them when she has not. Controlled drugs are safely managed and records are good. The owner has attended training about Care of Medicines. New cycles of medicines when received into the home must be signed and recorded as received on the MAR, some were found in the storage area and had not been recorded as received. The owner and manager were observed to address service users with respect and include them in all daily issues, such as what to do, what to have for lunch and in all general conversations. Hallewell, The DS0000017048.V323721.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): Standards 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to support service users personal choices of lifestyle, they also advocate where there is little known information and make arrangements for both service users to access required local services. Outcomes are positive and promote a healthy and individual lifestyle for service users. EVIDENCE: One service user attends day a centre which is next door five days a week, whilst at the centre the service user is able to meet with staff to plan activities, records maintained indicate that this service user is able to access communal facilities such as shops and hairdressers, visit local parks and at times take day trips out to theme parks. One service user does not leave the home very often, however he does go shopping with staff and also to the post office. This service user is also involved in domestic activity and enjoys watching specific television programmes. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 13 Service users are provided with generally healthy meals, the owner and her husband know their choices and preferences, and the owners’ husband does the majority of cooking. Service users were seen to enjoy their lunch. One service user has her lunch meal at the day centre on five days of the week. There were also records that one service user does at times eat out at restaurants or pubs. The food stocks were very good and provided service users with lots of choice to decide what meals they both would like. It is often the case that family meals are cooked. Hallewell, The DS0000017048.V323721.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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has provided some evidence that complaints would be taken seriously and effectively managed to improve service to service users, however protecting service users from abuse is a concern as it was not evident that current measures would be adequate and this may leave the service users at risk. EVIDENCE: A complaints policy is available, how complaints are managed was discussed with the owner who advised how she would manage them, she said it was important to quickly improve where it was needed. The complaints records were blank, there have been no complaints to the home or the Commission in the past twelve months. There is a policy about how to protect the service users, it is not adequate and does not meet the recommendations outlined in the Department of Health document “No Secrets” or with local Multi Agency guidelines. The owner was asked about how she would manage concerns about abuse and her immediate response was to make things safe and report it to relevant agencies such the police, social workers, the Commission and a doctor. The owner and her husband provide the majority of support to both service users, with the owner Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 15 providing all personal care, however she has not undertaken appropriate training to protect the service users from abuse. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 21, 23, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that the environment is a pleasant and family orientated premise with many positive features and facilities. However there are some health and safety concerns, which put residents at risk and need to be quickly made safe. EVIDENCE: Service users rooms were homely, well decorated and personalised with ornaments and personal items. Both rooms had no water supply to the wash hand basins (hot or cold) as the service users use different bathrooms and toilets. There are two bathrooms, both domestic and pleasantly decorated. In one bathroom there were three nails brushes that should only be used in service users rooms. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 17 One bedroom is a shared room occupied by one service user at present, privacy screens are available and there is adequate storage for two service users. The kitchen and dining area are clean and tidy, well equipped and used often as a communal / family area. There are two lounges, both domestic and decorated with ornaments and family mementos, they are well equipped and have satellite television and radio and music stereo systems. There is comfortable seating, they were warm, bright and pleasant. There is a large conservatory at the rear of the building leading to a wellmaintained rear garden. The conservatory needs to be kept clear of such items as tools, ladders and car batteries. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that the two service users are supported by a small team of staff, who are available at all times to meet their needs, who are well trained and who have a good understanding of mental health. Service users lives are happy in part due to the commitment of a family orientated service. EVIDENCE: The owner advised that other than herself, her husband and a volunteer no other staff provide support in the home to service users. The registered manager provides support with paper work and policies. There have been no new staff appointments. The volunteer does have a criminal records bureau disclosure, however references are needed. The owner who is continuously on duty should consider taking some time off to ensure she is rested between shifts. She has been trained in health and safety, moving and handling and completed some modules of training in mental health. The owner and her husband live at the home and provide sleeping in support to service users. The owner does need to undertake first Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 19 aid training. The owner and her husband who do all cooking have both completed basic food hygiene training. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been able to fully demonstrate that the management and administration of the home is effective to meet the service users’ needs and provide a positive and family approach to their care, improvements are needed to ensure that the views and opinions of service users are sought and where needed improvements made. EVIDENCE: The manager advised that she had completed the Registered Managers Award and had also completed National Vocational Qualifications in care. She explained how the owner is supported with paperwork and with policies, as she is the registered manager and owner for the services next door. She provided Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 21 new care planning documents to be implemented in 2007 and also how her home had commenced quality audits and reports, she advised that she planned to assist the owner to do this at The Hallewell, at present there is no formal method of quality audit, monitoring and reporting. The home does have a Statement of Purpose that commits the home staff, service users and family to provide a quality service. At present there are no home or family meetings. Risk assessments were available for fire, COSHH, food hygiene, staffing, laundry and managing infection control. Records were available they indicate that fire alarms are regularly tested, that the gas and electric are safe and that the stair lift is serviced. The water temperatures are recorded, this was somewhat confusing as it records the temperature of the hot water from all outlets including from the residents rooms (where the water supply is not connected). The manager and owner advised that the temperature is taken from the boiler thermostat and not from each outlet. There were some concerns about fire safety including as under the stairs was a concern as many combustible items were being stored. The owner has since notified the Commission that these have been removed. Residents have their own bank accounts. Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 3 X 3 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement Timescale for action 28/02/07 2 OP7 3 OP8 4 OP9 5 OP9 The registered persons must ensure that care plans include the abilities of service users and specifically record how staff provide care and support. 15(2)(b)(c The registered persons must ) ensure that care plan reviews record whether the care plan has been effective or otherwise. 12(1) The registered persons must 13(4)(b) ensure that risk assessments 15(1) and where needed risk management plans are completed for service users; these must include nutrition, moving and handling, falls and mental health. 13(2) The registered persons must ensure that medications are signed and recorded as received when they are received at the care home on the medication administration record. 13(2) All Medication must be signed for as administered at the time of administration. Previous timescale of 01/09/05 not met this requirement is carried DS0000017048.V323721.R01.S.doc 28/02/07 31/03/07 24/01/07 24/01/07 Hallewell, The Version 5.2 Page 24 6 OP18 7 OP18 8 OP20 9 OP24 10 OP26 11 OP29 12 OP30 13 OP33 14 OP38 15 OP38 forward. The registered persons must ensure that all staff receive appropriate training as a measure to prevent service users being harmed or suffering abuse. 13(6) The registered persons must ensure that the policy for protecting residents from abuse is reviewed and updated to include local multi agency guidelines and recommendations of the Department of Health paper “No Secrets”. 23(2)(e)( The registered persons must h) ensure that the rear large conservatory is kept clear of clutter and is at all times safe for residents to use. 23(2)(j) The registered persons must ensure that the water supply to the wash hand basins (hot and cold) in service users rooms is reconnected. 13(3) The registered persons must ensure that nailbrushes are removed and not used in communal wash facilities such as bathrooms. 19(1)(b) The registered persons must Sch 2(5) ensure that at least two written references are completed for volunteers working in the home. 18(1)(c)(i The registered persons must ) ensure that all staff in the care home are trained in first aid. The owner should consider completing the appointed first aid course. 24(1) The registered persons must establish and maintain a system for evaluating the quality of services at the care home. 13(4), The registered persons must 23(4)(b)(c ensure that combustible items )(iii) and or materials are not stored under the stairs. 13(4)(a) The registered persons must 13(6) 18(1)(c)(i ) DS0000017048.V323721.R01.S.doc 31/03/07 31/03/07 24/01/07 24/01/07 24/01/07 28/02/07 31/03/07 31/03/07 24/01/07 24/01/07 Page 25 Hallewell, The Version 5.2 ensure that the water temperature from all hot and cold outlets is regularly taken and recorded. 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 Hallewell, The DS0000017048.V323721.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000017048.V323721.R01.S.doc Version 5.2 Page 27 - 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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