Inspection on 13/03/06 for Halwill Manor Nursing Home

This inspection was carried out on 13th March 2006.

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

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

Other inspections for this house

Halwill Manor Nursing Home 31/07/07

Halwill Manor Nursing Home 29/03/07

Halwill Manor Nursing Home 13/06/06

Halwill Manor Nursing Home 18/10/05

Halwill Manor Nursing Home 26/01/05

Halwill Manor Nursing Home 25/05/04

Halwill Manor Nursing Home 20/01/04

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

CARE HOMES FOR OLDER PEOPLE Halwill Manor Nursing Home Halwill Beaworthy North Devon EX21 5UH Lead Inspector Susan Taylor Unannounced Inspection 13th March 2006 16:30 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 Halwill Manor Nursing Home DS0000026717.V295814.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. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Halwill Manor Nursing Home Address Halwill Beaworthy North Devon EX21 5UH 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) 01409 221233 01409 221265 Mrs Jacqueline I Mirjah Vacancy Care Home 25 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13), Old age, not falling within any other category (25) Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Notice of Proposal to Grant Registration for staffing/environmental conditions of registration issued 5/8/1997 The maximum number of placements including that of the named individual, will remain at 25 To admit one named service user, named elsewhere, outside the categories of Registration as detailed in the Notice dated 4th August 2005.. 18th October 2005 Date of last inspection Brief Description of the Service: Halwill Manor is a privately owned care home registered to provide nursing care. It is located in the heart of Halwill and has strong links with the local community. The home is set back off the road and is situated in large and accessible grounds. Parking is provided and access to the home is level. The house is old and large, it has been adapted to suit the needs of people with mobility problems and care needs. There is a lift to help those with limited mobility to access all floors. On the ground floor there is a large lounge and dining room; a smaller sitting area is adjacent to the main lounge off which are two offices. Two kitchens, a laundry, sluice room, staff rest room and residents’ rooms are also on the ground floor. Home cooked meals are cooked on site. Activities and entertainment are arranged for residents. The atmosphere is relaxed and friendly yet professional. Qualified nurses are on duty 24 hours a day to oversee the nursing needs of residents. The staff work hard to provide a homely environment whilst also striving to deliver quality care to residents. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took fourand a half hours during the evening. The purpose was to follow up requirements made at the last inspection, and key standards covering staffing and management issues. The inspector looked at records, policies and procedures. A tour of the building took place. Five residents gave their views of the home to the inspector. Two staff and the nurse in charge were interviewed. The people living at Halwill Manor prefer to be referred to as ‘residents’. Therefore, this term is used throughout the report. Their comments included: “I love it here, have the freedom to go out when I want, the food is lovely, and there’s nothing that is too much trouble for the staff”. “I like it here, the staff are caring and very kind”. “I feel like one of the family”. What the service does well: What has improved since the last inspection? What they could do better: Recruitment practices are poor and would not ensure that suitable people care for residents’. An immediate requirement was made in respect of this. The provider was asked to take up references, CRB and POVA checks of all new staff by 13th April 2006. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 6 Halwill Manor does not yet have a registered manager. The findings in respect of poor recruitment practices, quality assurance and health and safety issues reflect this position, which needs to be addressed as a matter of urgency. A requirement is made in respect of this. Quality assurance measures need to be reported upon to the Commission and other people such as residents, relatives and social services departments. A requirement is made in respect of this. Residents and staff at Halwill Manor do not yet benefit from staff receiving regular supervision. A recommendation is made in respect of this. Shortfalls were evident in respect of the management of health and safety issues, which leave residents, staff and visitors at risk. An immediate requirement was made at the inspection, which the provider had to deal with the same day. 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. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 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 Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 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): None EVIDENCE: Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 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): None EVIDENCE: Halwill Manor Nursing Home DS0000026717.V295814.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): None EVIDENCE: Halwill Manor Nursing Home DS0000026717.V295814.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): None EVIDENCE: Halwill Manor Nursing Home DS0000026717.V295814.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): None EVIDENCE: Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 13 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 Caring staff, in sufficient numbers ensures that residents needs are well met. The home has made some progress with training and development for staff, and this will ensure that competent and knowledgeable staff care for residents. Recruitment practices at Halwill Manor are poor and therefore fail to protect residents. EVIDENCE: Duty rosters covering a four-week period were examined and demonstrated that staffing levels were satisfactory. The inspector observed that staff appeared relaxed and responded to residents needs promptly. Five residents who the inspector met verified that they were well cared for and their needs were met. The nurse in charge verified that five new staff had been appointed in the last 12 months. Three personnel files were inspected. None of the files met the requirements of schedule 2. Satisfactory references, including CRB and POVA checks had not been obtained for two out of three new staff. Evidence of identity or a statement of the individual’s health also had not been obtained. An immediate requirement was issued in this respect, which required the provider to obtain satisfactory references for two staff and for their work to be supervised until this information was obtained. The administrator showed the inspector records that verified that four care staff are working towards NVQ awards. Care staff verified that training was Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 14 regularly offered to them. Recent training events had covered manual handling, infection control and procedures in the event of a fire. Records also demonstrated that the professional development of nursing staff was encouraged to ensure that PREPP requirements are met. Certificates were seen on the files, which included infection control and wound management. Halwill Manor Nursing Home DS0000026717.V295814.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): 31, 33, 35, 36, 38 Halwill Manor does not yet have a registered manager. The findings in respect of poor recruitment practices, quality assurance and health and safety issues reflect this position, which needs to be addressed as a matter of urgency. Some progress had been made towards the development of quality assurance systems in the home. It was evident that resident’s, staff and visitor’s views are respected in this home. However, the outcome of these measures need to be collated and reported upon to meet the current legal requirements. Overall, financial procedures safeguard residents’ interests and only minor additions are recommended to strengthen these further. Residents and staff at Halwill Manor do not yet benefit from staff receiving regular supervision. Shortfalls were evident in respect of the management of health and safety issues, which leave residents, staff and visitors at risk. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 16 EVIDENCE: The Commission received, and has been processing an application to register a manager since July 2005. As reported previously, this has been hindered because the applicant has failed to obtain a CRB check that is countersigned by the Commission. This has been brought to the attention of the applicant and provider. Residents told the inspector that they that they were often asked their views about the home in an informal way. Their comments included: “I love it here, have the freedom to go out when I want, the food is lovely, and there’s nothing that is too much trouble for the staff”. “I like it here, the staff are caring and very kind”. “I feel like one of the family”. According to records held by the Commission, an annual quality assurance report had not been received. The administrator for the home told the inspector that the provider and acting manager were in the process of doing the Registered Manager’s Award, and quality assurance is an area yet to be covered. The inspector was shown letters and a file that verified this. The home’s administrator had implemented an internal auditing system of the accounts and the inspector was shown these. Meals provided every day had been documented, and the record included comments received from residents. Staff told the inspector that meetings were held infrequently. Records showing how money is managed on behalf of residents were inspected. These were well kept, and accurately recorded the correct balance seen. Entries had not been signed for and a recommendation is made in respect of this. Receipts corresponded with entries for items such as chiropody, hairdressing and newspapers. Secure facilities are used to safeguard resident’s money. Three personnel files were inspected. None of the files contained evidence to demonstrate that new staff had received an induction that met national standards. Four supervision records were seen, which verified that irregular supervision had been provided for staff. Records showed that staff had last attended 1:1 supervision sessions in May and June 2005. The nurse in charge told the inspector that appraisals are conducted in the home. No records were seen that verified this. Comprehensive Health & Safety policies and procedures were seen, including a poster displayed near to the office. The poster did not state who in the home was responsible for day-to-day health and safety. A recommendation is made in respect of this. Since the last inspection, a member of the team had started a Health and Safety course to NEBOSH standards. Certificates verified that staff had attended infection control and manual handling training in the past Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 17 12 months. The inspector was shown hand sanitizer being used by staff to minimise the risk of cross infection. Records of accidents were kept and showed that appropriate action had been taken. Fire drills, alarm checks and maintenance had taken place regularly. Whilst touring the building, a hoist used to transfer residents was seen in front of a first floor fire exit, thus preventing safe egress from the building in the event of fire. Additionally, there was no evidence (service sticker) on the hoist to verify whether the equipment had been regularly maintained. An immediate requirement was made in respect of this that required the provider to remove the piece of equipment from the fire exit the same evening, and to provide evidence to show that maintenance had been carried out. Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 3 2 x 2 Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 19 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 OP29 Regulation 19 (1)(b)(i) Requirement The registered person shall not employ a person to work at the care home unless - subject to paragraph (6), (8), (9) her has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 9 of schedule 2. An immediate requirement was issued on 13/3/06. The registered manager shall appoint an individual to manage the care home where there is no registered manager in respect of that care home. Timescale for action 13/04/06 2 OP31 8 24/04/06 3 OP33 24(2) 4 OP38 23(2)c This requirement is carried forward from previous inspections. The registered person shall 31/08/06 supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. The registered person shall 13/03/06 having regard to the number and DS0000026717.V295814.R01.S.doc Version 5.1 Page 20 Halwill Manor Nursing Home 5 OP38 23(4)b needs of the service users ensure that – (c ) equipment provided at the care home for use by service users or persons who work a t the care home is maintained in good working order. An immediate requirement was issued on 13/3/06. The registered person shall after consultation with the fire authority – (b) provide adequate means of escape An immediate requirement was issued on 13/3/06. 13/03/06 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 OP35 Good Practice Recommendations There should be two signatures - one of the person making the entry and one of a witness - for all entries where residents money is managed or kept for safe keeping. A responsible person working at the home should be identified as being responsible for day-to-day health and safety issues. The health and safety procedure, and poster displayed should state that person’s name and title. All new staff should complete an induction training that meets Care Skills standards. Records should be kept. Supervision should occur regularly for all staff, and records should be kept up to date. 2 OP38 3 OP36 Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Halwill Manor Nursing Home DS0000026717.V295814.R01.S.doc Version 5.1 Page 22 - 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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