Inspection on 09/06/05 for Hames Hall

This inspection was carried out on 9th June 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

Hames Hall 24/04/07

Hames Hall 20/02/06

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 09 June 2005 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 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 F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hames Hall Address Gote Brow Cockermouth Cumbria CA13 0NN 01900 827601 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cumbria Nursing Services Denise Mason Care Home 25 Category(ies) of OP - Old Age registration, with number of places Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 November 2004 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 provided assisted bathing and seventeen of the bedrooms have en- suite facilities. There is a passenger lift between the two floors to provide easy access. The gardens are accessible from the house and are well maintained. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 over one day. Mrs Marian Peacock, Deputy Manager was on duty and in charge of the home whilst the manager was on annual leave. 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. What the service does well: What has improved since the last inspection? There had been a good practice recommendation from the last inspection that a system for formal staff supervision should be fully implemented by the manager. In some cases the work had been done towards achieving a regular formal supervision programme. However staff shortages had meant that the recording of some of these sessions had not been completed. Staff said that they felt fully supported by their line managers and met with them frequently to discuss day – to - day matters concerning the care for service users. The good practice recommendation will remain in place until the formal one to one supervision has been fully implemented. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 6 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. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 standard(s) 1, 2, 3,4 ,5 The home provided service users and their family carers with a comprehensive range of information about the home to help them to make an informed decision whether the home would be able to meet their needs. EVIDENCE: The home’s brochure has details about the range of services it provides. There was a clear admissions procedure to the home that included a full assessment of need being carried out. The managerial staff team were aware of the registration categories and had been careful not to admit anyone into the home whose needs were outside the categories. It was routine to issue all service users with an individual contract and terms and conditions. The contracts clearly stated the terms of residency and included trial periods. Visitors are welcomed into the home without an appointment at any reasonable time. Visitors spoke warmly of being made to feel comfortable and welcome and said that they were usually offered refreshments during their visit. All admissions are planned and Hames Hall does not provide intermediate care. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 The home used a clear and consistent care planning system which ensured that the health and social care needs of the people who lived in Hames Hall were met in a dignified way. EVIDENCE: The home had a policy that all prospective service users received a visit from the manager to make an initial assessment of their needs and capabilities. The resulting information enabled both parties to make an informed decision whether or not Hames Hall would be suitable for them. The information from this assessment formed the basis for the individual plan of care for service users. Most of the care plans provided staff with the necessary information to enable them to meet the needs of the service user. However there were a number of omissions, For example, one care plan did not have an up – to – date photograph of the service user that could be used for identification purposes in an emergency. Two care plans did not have an inventory of personal possessions that had been brought into the home, and none of the plans seen had been signed by the service users to show that they agreed with what had been planned. Records of visits by GPs and other health care appointments had been kept on file. Service users who spoke to the inspector confirmed that the staff assisted them to keep appointments to see the Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 10 chiropodist, dentist and optician. A local doctor was attending the home to see patients who were unable to visit the surgery. Staff had been given training in the storage and administration of medication. The records were in order and the medication procedures had been followed to ensure the safety and well being of service users. In the past adequate storage facilities had been provided for service users who took over the responsibility for their own medication. Currently there was nobody who kept and administered their own medication. The records showed that the home’s staff group are committed about ensuring the health and safety and wellbeing of the service users, themselves and colleagues. Staff members spoke to service users politely, using their preferred name and they knocked on bedroom doors before gaining permission to enter. Service users said that staff were courteous and said that their personal care was handled in a way that preserved their dignity. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 Service users are given support to take advantage of the opportunities available locally to enrich their lives. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The service users were very positive about their experiences of living in Hames Hall. They said that they were “free to do whatever they liked and at times to suit themselves.” They were able to pursue their own interests and hobbies and come and go as they pleased. Others said that the management expected their staff to “work to very high standards” which they appreciated, and it was “like living in a special hotel.” Visitors said that they were made to feel welcome and confirmed that the standards were maintained at a high level. The majority of the service users had their midday meal in the dining room. Some service users who needed more assistance had their meals served in their own rooms. The menus offer a range of choices at all meals. Service users said that the food was “always very good and varied and if we don’t like something then we say so, and have something else.” Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 12 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 standard(s) 16, 17, 18 The home has a satisfactory complaints procedure in place to protect service users from abuse. EVIDENCE: Service users had been given information about how to complain when they moved into the home and the complaints procedure had been included in the Service Users’ Guide. Service users said they would take up any complaint with the manager if necessary although they said that they had no reason for concern. The home had not received any complaints since the previous inspection. Service users who wished to vote in the recent general election had maintained that right by registering for a postal vote. The home’s “whistle blowing” policy was in place and clearly understood by staff members who knew what their role and responsibilities were in order to protect vulnerable people in their care. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20 21, 22, 23, 24, 25, 26 The standard of the environment in this home is good providing service users with an attractive and homely place to live in. EVIDENCE: The home was generally well maintained and provided a safe environment for its residents. The private bedrooms were spacious, clean and tidy and had been furnished to provide a comfortable and homely environment. All had many pictures and personal furniture, possessions and ornaments that made them very personal and individual. Seventeen of the bedrooms had en-suite toilets and some had a private bathroom. The communal living spaces were spacious and beautifully decorated and furnished to a high standard to provide a comfortable environment. Ramps and handrails had been fitted to assist people to move around independently. There is a passenger lift to allow easy access to the two floors. Equipment had been installed in the bathrooms to assist service users to take baths in safety and to promote independence. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 14 All parts of the home including the kitchen were immaculate to provide a clean and hygienic environment for the benefit of service users, staff and visitors. Service users and a visitor confirmed that the housekeeping staff maintained this high standard as the norm. The garden was attractive and well maintained and ramps enabled safe and easy access to and from the house. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Members of staff have a good understanding of the service users’ support needs. This is evident from the positive relationships that have developed between staff and service users. EVIDENCE: There were sufficient members of staff members on duty plus the deputy manager, who is a trained registered nurse, to meet the needs of service users. Staff members were seen to respond to the requests from service users in a prompt and efficient manner. Two waking care staff were on duty each night. The home‘s recruitment policy had been designed to protect service users. The deputy manager said that although the home had experienced difficulty in recruiting suitable staff they had pulled together as a team to ensure that standards had been maintained. The staff shortages had sometimes meant that staff worked overtime. To protect the interests of the service users each new member of staff completed a comprehensive induction programme when starting work in the home. Staff would not be employed until they had received clearance for the Criminal Records Bureau. All care staff were offered the opportunity to complete an NVQ in care and more than half the team had achieved the award. The home kept records of training given to staff. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 16 The policies and procedures in place were thorough and these contributed towards the protection of service users. For example the fire log was up to date with all tests having been completed on time and staff had been given training on the protection of vulnerable adults. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37, 38 The home was managed effectively to ensure that staff provided the best possible quality of care for the service users. However there was a shortfall in the way that staff were formally supervised on a one to one basis. EVIDENCE: Formal staff supervision between the supervisors and the care staff had been planned and, in some cases, implemented. However some supervision sessions had taken place but there were no records on file to confirm this. This shortfall is partly due to the manager and her deputy having to cover vacant posts in addition to doing their own job. Therefore they had been unable to complete the formal record of the sessions to their own high standard. The good practice recommendation that was made at the previous inspection will remain in place until the supervision programme has been fully implemented. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 18 The records showed the home’s staff group are committed about ensuring the health and safety and wellbeing of the service users, themselves and colleagues. Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x 2 3 3 Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 20 No 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 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. 1. Refer to Standard 7 Good Practice Recommendations The manager should ensure that the care plans include the necessary information and show that they have been completed with the involvement of the service user whose signature confirms this. The manager should ensure that all formal one to one supervision takes place and is recorded with a copy kept on file. 2. 36 Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Hames Hall F58 F10 s22654 hames hall v225827 090605 ui stage 4.doc Version 1.30 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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