Inspection on 16/05/06 for Hallgarth

This inspection was carried out on 16th May 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 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

Hallgarth 17/10/05

Hallgarth 01/12/04

Hallgarth 23/06/04

Hallgarth 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Hallgarth Hallgate Cottingham Hull East Yorkshire HU16 4DD Lead Inspector Ms Wilma Crawford Key Unannounced Inspection 16th May 2006 09:30 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 Hallgarth DS0000019678.V295406.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. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hallgarth Address Hallgate Cottingham Hull East Yorkshire HU16 4DD 01482 842115 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) Hollyfield Limited Mrs Agnes Abdelli Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Hallgarth is a detached two storey building situated in the centre of Cottingham, providing personal care and accommodation for up to forty people some of whom may have a dementia care need. The home is within easy access to all local amenities and local transport. The accommodation is arranged on two floors with a lift providing easy access for the residents. There are communal areas available on both floors. All but two rooms are for single occupancy. There is an ongoing programme of redecoration and renewal and those bedrooms that have been refurbished offer en suite facilities. The refurbishment of the building continues with bathrooms and toilets being refurbished to a high standard. There are pleasant gardens to the front of the building and a patio area to the rear offering pleasant surroundings. Fees charged by the home are from £323 to £368.50 plus a top up of £20 for a basic room or £30 for an en-suite room. Additional charges are made for chiropody, hairdressing and newspapers. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over eight hours including preparation time. Seven residents, five relatives, four staff and a ‘pat dog’ visitor were spoken with during the inspection. The manager was available throughout. The main method of inspection used was called case tracking which involved selecting five residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of five residents and four staff were inspected. The comments and views of people spoken with are included within this report. What the service does well: What has improved since the last inspection? The home has worked hard to address the number of requirements made at the previous inspection. 50 of the current staff team have achieved NVQ level 2 or above. A comprehensive training plan has been developed to ensure that all staff receive the training they require and training is regularly reviewed. The home has developed an in depth Quality Assurance system which covers all aspects of the home. This includes; resident’s care, training, environment, consultation with residents, relatives, visitors and professionals, activities, Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 6 menus, staff supervision and appraisals. The home also have achieved ‘The investors in People Award.’ The requirements made at the last inspection have been acted upon. Two staff and a driver have been appointed to enable the current activities programme to be further developed. A designated laundry person has been identified and additional ancillary staffing hours has been made available. 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. Hallgarth DS0000019678.V295406.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 Hallgarth DS0000019678.V295406.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” The home carries out care assessments on all prospective residents prior to admission. The home does not provide intermediate care. EVIDENCE: Evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the home confirming that they can meet the residents care needs or not. Discussion with residents and relatives also confirmed that this happened. Residents being case tracked were not always able to give a considered view of the care they receive, in these situations their relatives were consulted on their behalf. Comments included; ‘I can’t speak highly enough about the staff. Mum likes to keep herself to herself, her wishes are respected and tea is served in her room at her request. We are involved in all aspects of mum’s care and we are very happy with the care provided.’ Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” The care plans offer the staff good information on which to base their daily care, and the residents health needs, privacy and dignity are met The policies and procedures in place ensure the safe handling and administration of medication for the people who use the service. EVIDENCE: The resident’s care plans seen showed that they are developed from the initial needs assessment carried out by the home. Reviews of the plans are monthly to ensure that they are still current and any new issues have been addressed. Risk assessments are available, including a falls risk assessment. These show how each person has had risks assessed that are relevant to them. There is evidence that all residents have access to relevant health care professionals. Care plans evidence that health care professionals visit the home and that residents when required visit the hospital. Five visitors commented that they are happy with the care provided and confirmed that their relatives see the GP, district nurses, and the chiropodist. Residents said that they were consulted about their care and were aware of their care plans. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 10 Resident’s files also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. Care staff were seen to treat residents with respect and dignity during this inspection. The home’s accident book was examined and it was found that accidents occurring to residents have been recorded appropriately in their individual file. This information is also made available to the Commission by the home. The home uses an approved Monitored Dosage System for the administration of drugs. Medication records showed that all drugs administered were recorded on the resident’s individual records sheet. There were no gaps in recording seen. Any drugs that are refused are disposed of safely and returned to the chemist for disposal. All staff that are involved in the administration of medicines have received relevant training. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” Relatives and friends of residents are made welcome as are visiting health care professionals. Meals are well managed and menus reflect a balanced diet. EVIDENCE: Residents said that the food at this home is varied and well prepared. They particularly enjoy the full cooked breakfast. One relative commented ‘ My husband has had a cooked breakfast all of his life. I never dreamed that I would find a care home that would continue to provide this for him.’ Menus were inspected and found to offer choices for all mealtimes. However, only one vegetarian option is currently available. Residents acknowledged that they were regularly consulted as to what vegetarian options they would like. The homes pre-assessment forms were seen and included residents’ dietary needs and listed their likes and dislikes. Staff spoken with, were aware of individuals personal likes and dislikes. Observations made by the inspector were that adequate numbers of staff are available at mealtimes to help residents. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 12 Five residents seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. All five visitors confirmed that they are made welcome at the home. One visitor said that the staff inform me of any changes in my relative. A resident confirmed that she could take her visitors to her bedroom. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. Residents and relatives meetings are held in the home and the outcome of these is used within the homes Quality Assurance Reviews. Residents and relatives are also consulted through the homes Quality assurance process. One resident stated “ I feel fully consulted about all aspects of my care and the day to day running of the home.” The home undertakes a variety of activities for the stimulation of residents and a record of these is maintained. During the morning of the inspection a hairdresser was visiting the home. Two staff members and a driver have recently been appointed to provide a range of activities to residents. Residents confirmed that a planned activities programme is in place within the home, but they also have the opportunity to go out into Cottingham, on day trips, attend church and coffee mornings. A ‘Pat dog’ visits the home every fortnight, a hairdresser visits and a church service are also provided in the home. Relatives also confirmed that activities take place in the home and one visitor stated that they join in activities with their relative. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” Residents and relatives are listened to and their views taken into account. Policies and procedures ensure residents are protected from abuse. EVIDENCE: The home takes all complaints seriously. There had been two complaints in the last year and both had been dealt with appropriately and within the agreed timescale. Residents and their relatives are made aware of the complaints procedure and the forms are available from care staff on request. A resident said, ‘I have never had to make a complaint but would know who to speak to should I need to.’ There is a Whistle blowing policy in place and a clear adult abuse policy. The home has a copy of local authority guidelines and ‘No Secrets’ document for reference. Staff have received Adult Protection training and spoke knowledgeably about abusive practices and what action they would take if this came to their attention An allegation of abuse was made by a carer last year and investigated by the police and social services. The allegation was found to have been dealt with by the home appropriately and within their Adult Protection procedures. Two residents spoken with confirmed that they felt safe in the home. One resident stated, “ I have never had any cause to make a complaint, but if I did Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 14 I’m sure that Agnes or the staff would take action. They would definitely sort it out.” She also said that she would feel confident about approaching staff with a complaint. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 15 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): 19,26 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” The home is well maintained and residents are enabled to personalise their rooms. The home is clean and tidy, with a pleasant smell throughout. EVIDENCE: The home maintenance book was seen and showed that the handyman carries out general maintenance. The home was found to be in a good state of repair with resident’s rooms personalised with photographs and other memorabilia. Residents commented that they were happy with their rooms. Since the last inspection further bedrooms, a bathroom, shower room and toilets have been refurbished. This now gives residents a range of washing and toilet facilities to choose from. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 16 A tour of the home by the inspector found it to be clean with no unpleasant odours detected. Residents and visitors alike said that the home is clean and there are no unpleasant smells. Since the last inspection the housekeeping staffing hours has been increased. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30. “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” Appropriate recruitment practices are in place. The staffing levels meet the needs of residents. The home provides adequate training for care staff EVIDENCE: The home now provides an induction training for all newly appointed carers. The home records all training undertaken by care staff and a training plan is in place for 2006. The home also carries out appropriate checks for all new workers before they commence work at this home. 50 of the staff team have achieved NVQ level 2 or 3.A further two staff are working towards NVQ level 3 and five towards level 2.The chef has an NVQ level 3 in catering and ancillary staff also have relevant work related NVQ awards. The duty rota showed that five staff numbers were available to meet the needs of residents during the day and three staff during the night in this home. Staff said that the numbers of staff on duty at the busiest times are able to accommodate the numbers of residents. One visitor said ‘The care staff are cheerful and friendly and there seems to be a lot of staff when I visit.’ Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 “Quality in this area is good. This judgement has been made using available evidence including a visit to this service.” The home is managed competently and the staff are supported and supervised to carry out their roles. The residents are involved in contributing to the running of the home. EVIDENCE: The manager is competent through her experience and qualifications to run the home. She has sixteen years experience of working with older people and has achieved NVQ level 4, she has also completed the Registered Managers Award. Staff said they are well supported and they are confident to approach the manager with concerns or ideas. The minutes from the recent residents’ meeting show that residents contribute and raise issues, and that action is taken to address these. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 19 The home has a quality assurance system, conducting regular surveys to monitor quality. The results of this have been very positive. However, the manager stated that should any action be identified from these, an action plan would be developed and implemented. Staff are regularly supervised both formally and during every day observation. Annual appraisals also take place. Assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are also kept. Records within the home are stored securely. Residents said they were aware that they can see them if they wish. Relatives and residents commented; ‘Agnes is excellent, she is always there and available to talk.’ A visit from Environmental Health had identified six actions to be taken, these have been acted upon. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training. Certificates were available showing that the shaft lift and bath hoists had been serviced six monthly. Electrical equipment had also been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 20 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 Hallgarth DS0000019678.V295406.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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