Inspection on 20/02/06 for Hames Hall

This inspection was carried out on 20th February 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

Hames Hall 24/04/07

Hames Hall 09/06/05

Hames Hall 11/10/04

Hames Hall 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Hames Hall Gote Brow Cockermouth Cumbria CA13 0NN Lead Inspector Jane Strawbridge Unannounced Inspection 20th February 2006 2:00 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 Hames Hall DS0000022654.V280150.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. Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hames Hall Address Gote Brow Cockermouth Cumbria CA13 0NN 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) 01900 827601 Cumbria Nursing Services Mrs Denise Mason Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: Hames Hall is a large Victorian country mansion situated in extensive grounds on the outskirts of Cockermouth. The house has been extended and adapted to provide accommodation for up to 25 older people. The home is decorated and furnished to a high standard providing comfortable and pleasant accommodation. There are two bathrooms that have been adapted to provide assisted bathing and seventeen of the bedrooms have en- suite facilities. A passenger lift provides easy access between the two floors. The gardens are accessible from the house and are well maintained. Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place during one afternoon. Mrs Marian Peacock, Deputy Manager was on duty and in charge of the home during the absence of Mrs Denise Mason, the registered manager. The inspector spent time talking with the residents either in small groups or individually and with the deputy manager and staff on duty. Records to do with the care of the residents and the day to day running of the home were looked at and the inspector visited all parts of the home. Towards the end of the afternoon Mrs Mason returned to the home and the inspector was pleased to have the opportunity to speak with her and talk about what had been seen during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Some work still needs to be done to complete the formal staff supervision records and this will be looked at during the next inspection. Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 6 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. Hames Hall DS0000022654.V280150.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 Hames Hall DS0000022654.V280150.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): 3, 5 The home uses an admission procedure that means prospective residents are confident that in their care needs will be met when they take up residence. EVIDENCE: The staff in this home welcomed enquiries from prospective residents or their representatives and encouraged them to visit at any reasonable time to see for themselves what services were provided. It was normal practice to meet with all prospective residents and make an assessment of their needs to ensure that the home would be the appropriate place for them to move into. Residents spoke warmly about their own experiences during their first visit and were most positive about their first impressions of the home. They said that everything that had been done then to make them feel welcome had continued after they had moved in and that standards were high. They also said that their visitors were always made to feel comfortable and welcome, and it was usual for them to be offered refreshments during their visits. Hames Hall DS0000022654.V280150.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): 11 Practices within this home mean that residents and their representatives are confident that their final wishes will be respected. EVIDENCE: This home has detailed personal files that contained a wide range of information about health and personal care needs, daily routines and preferences. Residents were encouraged to talk about their expectations and wishes after their death and these had been recorded. At their induction staff had been given training on how to work sensitively with residents who were in the final stages of their life and how to provide support for relatives. Community based health care workers were able to assist the staff to ensure that any resident who wanted to do so, would be enabled to remain in the home until their death. Staff said they were aware of each other’s needs and whenever required they would support each other. However, if necessary, counselling was available for any member of staff who may need it. Hames Hall DS0000022654.V280150.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 This home offers opportunities for residents to be involved in a range of social activities, hobbies and pastimes. EVIDENCE: The home encourages its residents and/or their relatives to provide a brief life history to include special anniversaries and events, preferences, interests, hobbies and pastimes to enable staff to work more effectively. Recently a new member of staff had become involved in organising more activities for residents. This had been a success and was appreciated by everyone who had been involved. Now there were plans for the care worker to be given additional responsibilities as the activities organiser to co-ordinate and develop a suitable activity programme to build on residents’ interests and hobbies. Residents said that so far they had enjoyed the entertainments, games and quizzes and they were looking forward to more. Hames Hall DS0000022654.V280150.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 The home has satisfactory policies and procedures in place to protect the people who live and work in this home. EVIDENCE: Residents and staff said that they knew whom to contact if they had a comment or complaint about the way the home was run. They were confident that their concerns would be listened to and taken seriously and that appropriate action would be taken to resolve matters. There had been no complaints since the previous inspection. All staff had been given training about recognising abuse and what to do if they suspected it was happening. A policy to protect a member of staff who may have to raise a complaint against a colleague was in place, and staff were confident that if necessary, this would be applied fairly and confidentiality would be maintained. Hames Hall DS0000022654.V280150.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, 26 This home continues to maintain its high standards of housekeeping and maintenance so that its residents live in an attractive environment that is safe, comfortable and homely. EVIDENCE: The housekeeping staff had ensured that all areas of the home were well kept, clean and tidy. Residents said that the home “always looked good” and all members of staff “were expected to work to high standards.” New carpets had been fitted in some bedrooms as part of the routine maintenance plan and when rooms became vacant they were totally refurbished in preparation for a new occupant. The kitchen was immaculately clean and tidy even though work was ongoing to prepare tea for the residents. Hames Hall DS0000022654.V280150.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): 28, 29 This home has competent and trained staff on duty at all times. EVIDENCE: Some new staff had been appointed since the previous inspection and all the necessary recruitment procedures and checks to protect residents had been done successfully. More than half of the care staff had achieved at least NVQ level 2 in care. The home’s training records adequately demonstrate the commitment of senior staff to deliver training and development opportunities for all of the staff. They show that mandatory training is given to newly appointed staff and subsequently the home gives all staff refresher training courses as part of a rolling programme. Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 14 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, 36, 38 This home has sound working practices that protect the health and well being of the people living and working there. EVIDENCE: Residents and staff were happy to talk about their experiences of living and working in the home. Everyone was very positive and said “Hames Hall is a good place to live, or work, in.” Residents said that the staff listened to any requests from them or their representative and their experience was that staff would do whatever they could to meet these. Since the previous inspection the home’s senior staff had been working on the omissions in the care plans and formal staff supervision programme to address the good practice recommendations. The care plans had been reviewed and signed by the residents or their representatives to show that they had been involved and had agreed with what had been decided. Progress had been made to record the formal supervision sessions for all members of staff. The appointment of a night supervisor to work with the night care staff and to provide them with Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 15 formal supervision had relieved some of the pressure previously experienced by the manager and her deputy. However some work still needs to be done to complete the records and this will be looked at during the next inspection. This home is highly committed to the wellbeing of the people who live and work there. All records of the mandatory regular checks relating to health and safety had been completed correctly and on time. A rolling training programme was in place to back up the home’s policies and procedures that ensured safe working practice, and staff had access to protective clothing and equipment. Hames Hall DS0000022654.V280150.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 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 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 3 Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 17 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 Hames Hall DS0000022654.V280150.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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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