Inspection on 09/01/06 for The Hallewell

This inspection was carried out on 9th January 2006.

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

The inspector 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 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 Susan Scully Unannounced Inspection 9th January 2006 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.V279297.R01.S.doc Version 5.1 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.V279297.R01.S.doc Version 5.1 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.V279297.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 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 DS0000017048.V279297.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place over a one-day period. Records were sampled pertaining to residents care plans, activities, rights and choices, Health and Safety, and Healthcare needs. Resident views were not obtained verbally but records showed how resident needs were met and have been included in the body of the report 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 DS0000017048.V279297.R01.S.doc Version 5.1 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 Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 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, 5 Information is available to all prospective residents and gives details about the home and philosophy of care. Pre visits are arranged to enable residents to have choice. Information contained in the policies and procedure confirmed the admission procedure. EVIDENCE: An assessment is completed before admission and includes objectives, measures of success and daily living tasks. For new residents, information would be provided with details of how the home operates and what the resident can expect. There have been no admissions for the format to be used. Relatives and friend are made welcome with unrestricted visiting times. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 The personal care needs of residents are met by knowledgeable and trained staff who consistently make sure residents are safe and comfortable. Healthcare needs are identified and actions taken to ensure other professionals are involved when the need arises. Medication procedures require updating to include an audit trail of medication coming into the home. EVIDENCE: The care plans and assessments were personalized and well maintained. The manager said residents are involved in the development of their care plan. This could not be confirmed with residents as they will not speak with anyone they don’t know. The manager and owner had a good knowledge of the care needs of residents. Healthcare appointments are recorded and residents pay regular visits to dentist and doctor when the need arises. New documentation demonstrates the care needs of resident are met. There has been significant improvement in the handling and storage of medication. An audit completed during the visit showed all medication was accounted for. One resident takes five tablets per week to the day centre, which is next door. The inspector visited next door to see how the medication was being stored. It was stored appropriately. The manager must obtain two Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 9 signatures when the medication is handed to the staff at the day centre. A complete audit trail confirmed what medication was in the home and the five tablets that had been taken to the day centre. Copies of prescriptions are not at present kept. The manager must be able to audit the medication coming into the home against prescribed medication so copies must be kept. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 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 the following standard(s): 12 Resident’s independence is promoted and their lifestyle is of their choosing with support when required. EVIDENCE: Every weekend residents go dancing or to the local club, this has been a routine the residents have enjoyed for many years. Residents appear comfortable and relaxed when communicating with the manager and owner. One resident’s task is to ensure the post is received each day, and helps with the preparation of meals on occasions. Residents move freely around the home and there are no restriction in place. The manager said “it is the residents home and they do what they want to do’’. “ they live like you or I if they want something then they have it’’. If they don’t want to go out they don’t’’. “Residents here are part of the family and treated as such’’. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 11 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): 16, 18 Complaints are dealt with promptly within the time scale identified in the Complaints Procedure and any action taken is fully investigated. EVIDENCE: When a complaint is made, information is recorded. A complaints procedure that outlines how to make a complaint and the time scale for a response were seen. Residents have a copy of the procedure on file. A record is kept of any complaints received, investigated and the outcome. The Hallewell operates in line with the Birmingham Muliti Agency Guidelines including whistle blowing. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 12 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, 20, 25, 26 Arrangements are in place to minimise risk so that the welfare and safety of resident is protected. The Hallewell is comfortable and clean with a good standard of decor and is maintained as a family home. EVIDENCE: The home was clean and fresh. Residents have their own bedrooms. Each bedroom was personal with many personal belongings. The communal lounge was nicely maintained with good communal space. The Manager and Owner promote independent living for residents. It was apparent from daily records that residents enjoy freedom of choice and have support when required. When speaking with the Manager individuality and respect was foremost. The Manager said it was very important for residents to have a stable and family home, and this was what The Hallewell was aiming to provide. Residents have been at the home for a number of years and have freedom of choice and are respected in the decisions they make. All the necessary checks with Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 13 equipment and regular service of appliances are completed to ensure the safety of residents. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 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 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): 28, 30 Residents care needs are met by knowledgeable staff who have cared for the resident for many years and know their likes and dislikes and how they want to be cared for. Training is completed in mandatory areas and updated as required. Supervision is held regularly. EVIDENCE: Staffing is made up of family members in addition a member of staff assists when required from the home next door that the owner also owns. Records of training and CRB checks were seen. Staff files were sampled that contained information and certificate of training that had been completed. It was clear from conversations with the owner/manager there are very clear standards by which the home should run, and thus ensures that high standards are maintained. It appears that the Hallewell has successfully achieved the aim to provide a family type environment. Supervision is completed on a regular basis. Information contained in supervision files shows topics discussed, such as policies and procedures, and any concerns they may have concerning the residents and training. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 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 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): 33, 38 The routine in the home is flexible and in the best interest of the residents. Health and Safety of residents is maintained to a satisfactory standard. EVIDENCE: The Hallewell is run as a family unit with the best interest of residents being taken fully into account. The manager demonstrated her knowledge regarding the residents’ needs. In general, all Heath and Safety checks are completed to a satisfactory standard. Fire regulations are maintained with the testing of all fire safety equipment, fire drills and weekly testing of fire alarms. A risk assessment is required for Fire Safety. Weekly fire safety checks are completed including fire drills. Not all hot water outlets are regulated with a safety valve and require regular checks to prevent scalding. Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 16 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 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 3 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 17 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 Standard OP9 Regulation 13(2) Requirement All Medication must be signed for as administered at the time of administration. (Previous time scale.) 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.) All water outlets must be regulated. All water outlets must have a water temperature check completed on a regular basis to prevent scalding. (Previous time scale.) Timescale for action 01/09/05 2 OP9 13(2) 01/09/05 3 OP38 13(4)(c) 01/10/05 Hallewell, The DS0000017048.V279297.R01.S.doc Version 5.1 Page 18 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.V279297.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Birmingham 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 DS0000017048.V279297.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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