Inspection on 24/04/07 for Hames Hall

This inspection was carried out on 24th April 2007.

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 20/02/06

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 Diane Jinks Unannounced Inspection 24th April 2007 10:00 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.V329486.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. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 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 F/P 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.V329486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 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. There are gardens, which are accessible from the house and there is a car parking area. The weekly fees for this home do not exceed £462.00 per week, although there are extra charges for hairdressing, magazines, chiropodists and other personal items that residents may wish to have. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assessment of this service included an unannounced visit to the home, discussions with the manager and meeting and talking to some of the people who live at Hames Hall. Comments about this home and the service it provides were received from residents, their friends and their relatives. During this visit all the key standards of the National Minimum Standards were assessed. The registered manager had completed a pre-inspection questionnaire prior to this visit. This assisted in verifying information throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are some gaps in the staff recruitment processes at the home. These matters were discussed with the manager during this visit. This will help to make sure that the shortfalls are dealt with quickly. Residents have their care needs assessed and recorded in their plan of care. Full nutritional assessments are not undertaken for residents on admission to the home. A recommendation has been made for the manager to review this matter. Nutritional assessments will provide baseline information to help Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 6 ensure that all aspects of the residents health and care needs are assessed and monitored. 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. The summary of this inspection report can be made available in other formats on request. Hames Hall DS0000022654.V329486.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 Hames Hall DS0000022654.V329486.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have received a comprehensive care needs assessment. This helps to make sure that the home can meet their needs and expectations. EVIDENCE: The manager at Hames Hall ensures that individual care needs assessments are carried out for each prospective resident. Admissions are not made until this assessment has been carried out and considered by the manager. This helps to ensure that the home will be suitable and able to meet the needs of the prospective resident. Records indicate that assessments are carried out in a professional, sensitive manner and involve the individual and their family or representative where appropriate. People living at the home said that they were able to visit and look around prior to moving into Hames Hall. The manager and the staff were said to have been very helpful and considerate of the needs and feelings of people about to move into the home. Hames Hall DS0000022654.V329486.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service are supported and helped to be independent and can take responsibility for their own personal care needs. EVIDENCE: Samples of residents care files were looked at during this visit. Individualised care plans are developed from the care needs assessment during the first few weeks of the resident moving into the home. They identify the tasks that residents need assistance with and also what the person can do for themselves. This helps to ensure that the independence and individuality of people living in this home is promoted and encouraged as much as possible. Care plans contain information about medical histories and a brief resume of their life history. From looking at the care records and discussions with residents, it is evident that they are involved in the production of their own care plans and individual wishes and choices are recorded. Care plans include an element of risk assessment suitable for meeting the needs and abilities of residents in a safely managed way. The sample of records looked at did not contain nutritional assessments but weight had been recorded on admission and is monitored from time to time. This level of monitoring was appropriate for these residents. Both care plans and risk Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 10 assessments are reviewed and updated at regular intervals. This helps to make sure that the changing needs and requirements of residents do not get overlooked by care staff. One relative commented that there is an ‘excellent level of care in all aspects. The friendly, helpful and caring staff deserve a special mention.’ One of the residents said ‘that the staff will help with anything but I like to be very independent. I know that if I need or want help I can get it. All the staff are very good.’ The records also show that people living at Hames Hall receive attention from health care professionals such as doctors, community nurses, chiropodists, opticians and hospital staff when required and are supported to attend appointments. The home has policies and procedures in relation to the administration of medication. The staff responsible for administering medication have undertaken training to help ensure that they are competent and able to carry out this task safely. Some residents have maintained responsibility for their own medication. This is managed within a risk-assessed framework, which is kept under review. Residents are provided with a safe place in which to store their medication. Samples of medication records were looked at during this visit and were found to be up to date and accurate. The service is efficient when caring for residents who are dying. As far as possible the manager will acknowledge and support their wishes. The manager ensures that specialist advice and support is obtained from community nursing services when required. Hames Hall DS0000022654.V329486.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Hames Hall are able to make decisions and choices in their daily lives. Activities are available to help meet the social, cultural and leisure needs of residents. EVIDENCE: Activities are available in the home and residents choose whether they join in or not. Residents are encouraged and helped to remain active and independent and are able to carry out light chores in the home if they wish. One resident said that she liked to keep active and helps with mending clothes, laying and clearing tables and arranging flowers. The activities available include weekly ‘keep fit’ classes, visits to places of interest and entertainers visiting the home, for example musicians, singers and contact with a local school. Church services are arranged in the home and again residents choose whether to attend or not. There are board games, quizzes and handicrafts available. The home has televisions, radio, music players in the communal areas. Some residents may have brought these items from their previous home for use in their own room. Visitors to the home are made welcome. Residents may choose to see their visitors in their own room or in one of the communal areas. Residents said that their visitors are ‘well looked after’ and would be provided with refreshments if they wished. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 12 The menus seen during this assessment of the home do not contain detailed information regarding the content of each meal, but they do indicate that residents are provided with a choice of food at lunchtime. Residents indicate that the food is very good and that they are always given a choice and extra alternative choices are available if needed. People with special dietary requirements said that the staff understand their requirements and provide a good and varied menu. A resident described the teas as ‘boring’ and another said that there is a lot of fish on the menu. They try to avoid fish ‘because of the small bones’. Residents are able to take meals in their rooms if they wish or in the dining room. The dining room is furnished to a high standard and is a pleasant and comfortable area. The tables were nicely laid up for lunch with wine glasses and napkins on each table. Staff were observed asking people about their choice of meals for the day from the menu. The lunchtime meal was served by the staff. They asked residents about sauces, gravy and condiments, providing assistance where required. The menus would benefit from a review, to include the views of residents and details of the types of vegetables/potatoes etc that will be served each day. The choices for the lunchtime meal are fairly detailed and the teatime choices should also be shown in the same way. One lady was seen to have a visit from the community nurse. She was helped to her room by a member of staff so that she could be seen in private. She was able to choose whether to use the stairs or the lift. The resident indicated that she preferred ‘to keep moving’ and chose to use the stairs. The resident was supported in a friendly and encouraging manner by the member of staff. Hames Hall DS0000022654.V329486.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are listened to and have their concerns taken seriously by the manager. EVIDENCE: There is a policy and procedure in place regarding the protection and mistreatment of vulnerable adults. The home has a copy of the local authority’s up to date guidance and procedures on this subject. Staff training records show that the manager ensures staff are aware of the procedures to follow should they suspect the mis-treatment of a resident. Residents are aware of whom to speak to if they had any concerns. One person indicated that they had raised concerns with the manager and that they had been dealt with in a satisfactory manner. The complaint process is on display at the home as well as included in the service user guide. Residents indicate that the staff and the manager are very approachable and feel confident that any concerns they may have would be listened to and taken seriously. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in clean, comfortable, warm and pleasant surroundings. EVIDENCE: The home is decorated and furnished to a high standard throughout and all areas were clean and fresh. Residents spoken to during this visit were very satisfied with the environment and very pleased with their own rooms. People living at the home are able to bring some of their own items to help make their rooms more homely and personal. Residents are provided with a safe place to store small items or medication in their own rooms. There is a programme of renewal and maintenance. Six of the en-suite bedrooms have recently been redecorated and new safety flooring fitted. New carpets, curtains and bedspreads have been purchased. Additionally, the home has had external painting of windows, doors, rendering and the fire escape. Some windows were repaired prior to the re-decoration. There are communal bathrooms in the home, which have been adapted to ensure that service users are supported appropriately with their personal care needs. Other aids and adaptations are available throughout the home, for Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 15 example raised toilet seats, grab rails and handrails. These help to promote and facilitate the independence of people living here. The kitchen and laundry areas were clean, tidy and appeared well organised. Some of the residents spoken to particularly mentioned the excellent standard of the laundry service at the home. There are extensive well-maintained gardens that are accessible to residents. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and well trained. This helps to ensure that the needs of people living at the home are met in a safe and appropriate way. EVIDENCE: Samples of staff recruitment and training records were looked at during this visit to the service. Prospective staff are required to complete application forms and undergo special checks such as Criminal Record Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) list checks. This helps to ensure that only suitable people are employed to work at the home. There are gaps in some of the recruitment records and this was discussed with the manager to help ensure that they are addressed quickly. Records show that staff are provided with and participate in training courses. Specialist training is provided to care staff in subjects such as dementia care and the safe administration of medication. Over half the staff working at the home have gained a National Vocational Qualification (NVQ) in care with further staff undertaking this award. This helps to ensure that residents are supported by competent staff that understand their needs and are trained to meet those needs safely. Sufficient numbers of staff were on duty on the day of this visit to the home. Some residents and visitors to the home indicate that in their opinion, there are times at the home when staffing levels fluctuate. Residents did say that staff are ‘very caring and compassionate’ and that ‘staff are often busy with their ladies and gentlemen but always have time for you’. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users by a competent and well-organised manager. EVIDENCE: The manager has completed the registered managers award and the Certificate in Management. She has participated in further training to help ensure that her knowledge is kept up to date. There are clear lines of accountability in the home, which helps to ensure the open and positive atmosphere at Hames Hall. The home takes care of a small amount of resident personal allowances (e.g. money for hairdressing, toiletries etc). Individual records are kept and money is kept separately. Two members of staff record and check any transactions and signatures are required. This helps to ensure that resident’s finances are protected and managed safely. There are accident reporting procedures at the home, which include a recording process. There is an accident book for staff to record any incident, Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 18 which involves them. Any accident or incident involving a resident is recorded in their individual plan of care. A special record card is kept for this purpose. In addition to this the manager ensures that notifications are usually submitted to the Commission for Social Care Inspection. The home has commenced a programme for quality assurance. Residents are surveyed regularly and are asked for their views on the home. Residents meetings also take place. The home has a comments and suggestions box prominently placed in the reception area. The manager carries out the morning medication round and takes this opportunity to talk to residents on a daily basis. Residents are able to discuss any issues with the manager. This helps to ensure that concerns are dealt with at an early stage and promptly. The Fire Officer has recently visited the home and carried out an audit of the service. The manager needs to update the fire risk assessment and an up to date format has been provided to the manager to help her with this task. Fire records were looked at during the visit to the home. Fire alarms and emergency lighting records indicate that these are checked each week. With further checks made of the fire fighting equipment and the fire detection/alarm system. Fire drills are carried out at frequent intervals and include day and night time practices for staff. Staff receive training and updates about the home’s fire procedures on a regular basis. This training is provided in various formats including formal lectures by the fire service, videos, questionnaires and through discussion at supervision sessions. A visit has been made to the home by the Environmental Health Officer and some recommendations were made. This was for the manager to review risk assessments and update them and also to ensure that the electrical installations at the home received their five yearly check. The manager confirmed that these matters have now been dealt with. Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 19 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hames Hall DS0000022654.V329486.R01.S.doc Version 5.2 Page 20 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. 1 Standard OP29 Regulation 19(1) Requirement The manager must ensure that two written references are obtained before appointing a member of staff. Where verbal references are obtained prior to receipt of the written reference, the manager must ensure that detailed notes are made and kept. This will help ensure that only suitable staff are appointed to work at the home. Timescale for action 31/05/07 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 OP8 Good Practice Recommendations It is recommended that nutritional assessments are carried out for each resident on their admission to the care home. This will provide baseline information to help ensure that all aspects of the residents health and care needs are assessed and monitored. It is recommended that the weekly menus at the home are reviewed to include detailed information about the choices DS0000022654.V329486.R01.S.doc Version 5.2 Page 21 2 OP15 Hames Hall available at each mealtime. Consideration should be given to the views and opinions of people using this service. 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