Inspection on 17/10/05 for Hallgarth

This inspection was carried out on 17th October 2005.

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 16/05/06

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 Unannounced Inspection 17th October 2005 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 Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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.V259026.R01.S.doc Version 5.0 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.V259026.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: Hallgarth is a detatched two storey building situated in the centre of Cottingham, providing personal care and accommodation for 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 and the entrance hall has been 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. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours. A tour of the premises was conducted with the manager. 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. Six residents, two members of staff and a relative were spoken with. 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 requirements made at the last inspection have been acted upon. At the time of the inspection a contractor was in the home to complete the electrical installations check. Risk assessments have been completed to assess the risk from unguarded radiators and pipes and scalding from unregulated water outlets. All newly refurbished rooms have radiator guards in place and thermostatic controls fitted. Where any risk has been identified in the rooms awaiting refurbishment, radiator guards have also been put in place. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 6 The entrance hallway has been refurbished to a high standard and a new carpet fitted. The renovation and refurbishment of the home was underway with minimum disturbance to the residents. The refurbished bedrooms and lounge areas greatly improved the general atmosphere in the home and residents and staff said that it made the home a much nicer place to be. 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.V259026.R01.S.doc Version 5.0 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.V259026.R01.S.doc Version 5.0 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): 1,2,3,4,5, Information is available on which prospective residents, current residents and visitor’s can make choices about the home. The home has a satisfactory assessment process in place to ensure that it can meet the needs of the people admitted to the home. Residents and relatives are happy with the care provided and feel that their needs are being met. EVIDENCE: A statement of purpose and service user guide, are made available to all prospective residents during the assessment process. The home has an admission policy and procedure, which includes an assessment being carried out prior to admission, this is undertaken to make sure that the home can meet prospective residents needs. This is confirmed in writing and residents spoken with, were able to confirm that this takes place. Resident’s records included contractual information and demonstrated that the home has a thorough assessment procedure. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 9 A staff member gave an account of the assessment process, which reflected the homes written procedure. Residents spoken to confirmed they liked living at the home and were aware that the home keeps records about them. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 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 medication procedures need to change to ensure they are safe and clearly recorded. Residents wishes concerning terminal care and arrangements after death are recorded and acted upon. EVIDENCE: The home uses an approved MDS system for the administration of drugs. Medication records showed that not all drugs administered were recorded on the resident’s individual MAR sheet. The Controlled drug record did not have two recorded signatures for all medication administered. Each resident has a care plan which is holistic and detailed this informs the way the staff should care for each of them. The plans are used on a daily basis, any changes to a persons care is recorded in the daily records. Not all care plans seen had been reviewed on a monthly basis. The five care plans seen included signatures, which show that the service users have been consulted. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 11 The residents said, the staff help them to get the health care they need and the care plans did show that the staff record when someone is ill, then seek medical attention and follow the advice or treatment. The residents said that their privacy is maintained when the staff, assist them with personal care, and were positive about the care the staff offer. The staff always knock on doors and they ensure that the door is always closed, before helping someone with personal care, therefore privacy is maintained. The home has a policy and procedure in regard to death and dying. The manager confirmed that in such situations additional staffing is made available to sit with the resident and their family. This also includes relatives and friends of residents who are dying being able to stay with them for as long as they wish, and residents wishes being respected as recorded in their care plans. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Relatives and friends of residents are made welcome as are visiting health care professionals. Meals are well managed and menus reflect a balanced diet. Residents’ likes and dislikes are recorded. EVIDENCE: The inspector observed residents having their tea. During discussion, residents said that the food at this home is varied and well prepared. Menus were inspected and found to offer choices for all mealtimes. The homes preassessment 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. Two residents seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. A visiting relative told the inspector that they and their family had been staying with their relative twenty four hours of the day, during their illness. They had always been made welcome by the staff Refreshments and a reclining chair had been made available for their comfort. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 13 Residents and relatives meetings are held in the home and the outcome of these is used within the homes Quality Assurance Reviews. One resident stated “ I feel fully consulted about all aspects of my care and the day to day running of the home.” Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home takes the issue of protecting residents from harm very seriously and has a comprehensive adult protection policy. EVIDENCE: The home has a ‘Whistle Blowing’ policy and staff have received Adult Protection training. Staff spoke knowledgeably about abusive practices and what action they would take if this came to her attention. The home has a copy of the local authorities adult protection procedures. The two residents spoken to confirmed that they felt safe in the home. One resident said, “If they thought it was necessary they would take action. They would definitely sort it out.” She also said that she would feel confident about approaching staff with a complaint. Residents confirmed that they are on the electoral role and use the postal voting system. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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): 19,21,22,23,24 Both private and communal space is suitable for the residents, homely and comfortable. The residents do have some adaptations and equipment that is needed, however the newly refurbished upstairs bathroom does not have a hoist, this limits the residents who can use this. EVIDENCE: The home has assessed the communal areas and the private rooms to ensure the residents are protected from risk wherever possible. The records show that where risks are identified they are minimised. Some bathrooms have been refurbished, but do not have hoists, to enable all residents to use them. The upstairs bathroom with a hoist is in need of updating. When the staff need to assist the residents to bathe, they are trained to use the suitable equipment that is provided. One resident said that the staff are kind and considerate when they help them to have a bath. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 16 Residents’ comments were positive about their bedrooms and each room viewed was individually decorated and furnished and contained personal items reflecting individual interests and tastes. One resident spoken with said that he particularly liked his room as he enjoyed the view of the garden. One resident showed the inspector their room, they had their own furniture and personal items and the room was well decorated. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 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 The staff group are an established team and staffing levels are sufficient to meet the current needs of residents. Staff are provided with training to ensure their competency and have the skills and experience needed to carry out their roles and are committed to the work they do. There is a satisfactory recruitment process in operation. EVIDENCE: All residents spoken to were complimentary about the care staff provide. A key worker system is in operation giving staff specific responsibilities for specific residents. All residents spoken to were aware of who their key worker was and all felt able to raise any problems with them should they arise. On the day of the inspection the manager, a care manger and five care staff were on duty on the morning shift, a care manager four care staff on the afternoon shift and one senior carer and two carers during the night. . All staff members spoken to felt that the current staffing levels were adequate. The home also employs an activities coordinator, handyman, administrator, housekeepers, chefs, and kitchen staff. Two members of staff said that they received an induction and that they have the opportunity to attend regular training courses. The training record confirms that courses are booked and attended. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 18 The staff have time to look at the policies and procedures and to discuss how they should be used. The staff also said they have time to talk to the residents. The residents said that the staff had time to care for them and they never had to wait long for help. Three of the care managers have NVQ level 2 and the third is waiting to begin this. Two care staff have NVQ level 2 and a further 8 are working towards this. Three domestic staff also have a relevant NVQ qualification. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 19 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): 31,32,33,36,37,38 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 is also completing 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 do contribute and raise issues, and that action is taken to address these. The home conducts regular surveys to monitor quality and the results have been very positive. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 20 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. In relation to two residents who had recently experienced a large number of falls, it could not be demonstrated that a risk assessment had been completed in relation to the possibility of further falls occurring and this is required. A resident was also seen being moved in a chair without footplates, causing their feet to drag along the floor. A resident using bed rails did not have protective fitted covers in available, duvets were being used for the purpose of protection. Records within the home are stored securely. Residents said they were aware that they can see them if they wish but one resident said, ‘I have no wish to see my notes but know I am able to’. A previous immediate requirement to obtain an electrical wiring certificate (to conform with the Electricity at Work Regulations 1989) was in the process of being addressed during the inspection. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 21 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 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 x 3 2 3 3 x x 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 3 3 X X 3 2 2 Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 22 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 OP3OP37O P38 Regulation 13(2) Requirement Timescale for action 30/11/05 2 OP7 14(2)(a)( b) 3 OP7 14(2)(a)( b) 4 OP9 13(2) The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. Trends in relation to falls need to be identified and acted upon sooner. Risk assessments /management plans should be in place for all residents experiencing falls The registered person shall 30/11/05 ensure that the assessment of residents needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. Care plans should be reviewed on a monthly basis. The registered person shall 30/11/05 ensure that the assessment of residents needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. The registered person shall make 17/10/05 arrangements for the recording, handling and safekeeping, safe DS0000019678.V259026.R01.S.doc Version 5.0 Hallgarth Page 23 administration and disposal of medicines received into the care home. An immediate requirement was left in respect of this. 5 6 OP19 OP22 23(b) 23(a)2(a) The programme for upgrading the premises must be completed. The registered person must demonstrate that an assessment of the premises and facilities has been made by a suitably qualified person, including a qualified occupational therapist, with specialist knowledge of the client group being catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of residents. This is particularly relevant to the newly refurbished upstairs bathroom. The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. Residents must only be moved on chairs that have footplates fitted to them. The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. Residents using bed rails must be provided with protective fitted covers. 28/02/06 30/11/05 7 OP38 13(4)( c ) 30/11/05 8 OP38 13(4)( c ) 30/11/05 Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 24 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 OP27 Good Practice Recommendations The home should consider how activities can continue to be provided during the absence of the activities coordinator. Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Hallgarth DS0000019678.V259026.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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