Inspection on 01/06/05 for Handsworth Methodist Home

This inspection was carried out on 1st 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Handsworth Methodist Home 24/07/07

Handsworth Methodist Home 05/09/06

Handsworth Methodist Home 06/12/05

Handsworth Methodist Home 21/01/05

Handsworth Methodist Home 17/06/04

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

CARE HOMES FOR OLDER PEOPLE Handsworth Methodist Home West Road Bowdon Altrincham, Cheshire WA14 2LA Lead Inspector Val Bell Unannounced 01 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. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Handsworth Methodist Home Address West Road Bowdon Altrincham Cheshire WA14 2LA 0161 928 5314 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) Methodist Homes for the Aged Responsible Individual Jane Elizabeth Barker Mr Mark Greenhalgh CRH Care home PC Care homeonly 41 Old age 41 Category(ies) of OP registration, with number of places Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All service users will fall within the category of old age and may additionally have a physical disabilty or dementia. The six bedrooms on the 3rd floor are not used for service users who require the use of wheelchairs or those who have poor mobility. Alternative accommodation will be provided should any service users living on the 3rd floor require it in the future. A minimum of four care staff are employed between 8.00am - 2.00pm and 6.00pm - 10.00pm and overall staffing levels will not fall below the minimum requirements set out in the Residential Forum guidelines, `Care Staffing in Care Homes for Older People`. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 21 January 2005 Brief Description of the Service: Handsworth Methodist Home provides residential accomodation with personal care for up to forty-one residents within the category of old age. Handsworth is a private care home owned by Methodist Homes for the Aged. Mr Mark Greenhalgh is the registered manager. Handsworth is a large purpose built property set in pleasant grounds that are enclosed and accessible to residents. The home is situated in a quiet residential area of Bowdon within easy reach of a post office, general store, church and local public house. The village of Hale is a short distance away and Altrincham is the nearest main town. The home is conveniently situated for local transport services and main motorway links. The home is arranged over three floors and a passenger lift provides access to all floors. All bedrooms are single and have en-suite facilities. Communal areas consist of a large dining room, several lounges, a conservatory, activities room and tea bays on each floor. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during the daytime on 1 June 2005. During the inspection the inspector talked to residents, visitors to the home and staff on duty. Five of the six requirements made at the previous inspection had been addressed and a further five requirements were made during this inspection. The home received a commendation for its efficiency in the administration of medication. What the service does well: What has improved since the last inspection? Since the last inspection it was noted that marked improvements had been made to information recorded in care plans. Additionally, Methodist Homes had begun to forward monthly Regulation 26 visit reports to the Commission for Social Care Inspection. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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 Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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, 3 and 6 Clear and comprehensive information is given to prospective residents. This enables them to make a decision on whether the home can meet their needs. The home’s failure to undertake mental health assessments places residents at risk of not having all their needs met. EVIDENCE: The inspector was given a copy of the homes Service User Guide. This document had been updated since the previous inspection. It provided comprehensive information to new residents and was written in plain English. The document needed to include a reference to the inspection reports provided by the Commission for Social Care Inspection. The inspector examined four residents care plans. Care Manager assessments of need had been obtained and thorough assessments of need had been undertaken by the homes senior staff prior to residents being admitted to the home. However, the home’s assessments did not include mental health needs. The home did not provide an intermediate care service. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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 and 10 Residents’ healthcare needs appeared to have been met. A safe system of medication was in operation at the home, which protected the welfare of residents. Residents were treated with dignity and respect by staff at the home. EVIDENCE: All residents had a care plan and most of these had been signed by residents. There was evidence that residents had access to medical intervention from the full range of community health professionals and the outcome of these visits had been fully documented in the care plans. Residents’ weights and bathing had also been recorded. The home had developed a useful information sheet that residents could take with them to hospital appointments. The information sheets detailed medical histories and current prescribed medication. The inspector assessed the homes administration of medication. Records were accurate and up to date and the member of staff responsible for monitoring medication had developed a robust system for safe administration. This was commended as an area of best practice. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 10 The inspector spent time talking to all residents in the lounges and dining areas. Without exception, all residents spoken to praised the quality of care provided by staff at the home. Comments made included, “The staff work very hard and nothing is too much trouble for them” and “I was worried about moving into a home, but it was the best decision I made to move in here”. The inspector also spoke to residents’ relatives who were visiting at the time of inspection. Visitors told the inspector that their relatives were treated with respect and dignity and were well cared for. Relatives commented that they were always made welcome when they visited. Staff had arranged a party to celebrate a residents birthday on the day of inspection and residents told the inspector that activities were provided for them on a regular basis. This is detailed in the section entitled, ‘Daily Life and Social Activities.’ Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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) 12, 13, 14 and 15 A lively programme of activities in the home provided stimulation and social interaction for the residents. EVIDENCE: The home employed an activities co-ordinator for 20 hours per week and a tutor from South Trafford College was also providing activities every week during term-time. The home had recently staged a VE day celebration for the residents who told the inspector that this had been most enjoyable. The home’s notice board displayed photographs of the special events provided for residents. The home was visited by Trafford Library Service every four weeks. Residents were observed to have a supply of newspapers and magazines and some residents were engaged in crossword puzzles during the inspection. A hairdresser visited the home twice per week and it was evident that residents were encouraged to take a pride in their appearance, as all the residents were smartly dressed. Residents’ preferences relating to social activities had been recorded in care plans along with their wishes regarding religious observance. Care plans also detailed the outcome of contact with the friends and relatives of residents. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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 and 18 The home’s format for the recording of complaints had the potential to compromise the privacy and confidentiality of residents. Robust procedures for the protection of vulnerable adults ensured that the welfare of residents was protected. EVIDENCE: The home had appropriate complaints policies and procedures in place and all complaints had been documented. However, these had been recorded in a hardback book, which did not comply with the requirements of the Data Protection Act 1998. Complaints must be documented separately to maintain confidentiality of information. The manager was involved in the Methodist Homes working party on training in awareness of abuse. Trafford Metropolitan Borough Council’s multi-disciplinary policy on the protection of vulnerable adults was in place at the home along with an in-house policy on abuse. In conversation with the inspector staff were able to explain the correct procedure to follow in cases of suspected abuse. The home also had a whistle blowing policy in place. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 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 and 26 Residents benefited from living in a clean and hygienic environment that was tastefully decorated and comfortably furnished. EVIDENCE: The inspector undertook a tour of the home’s bedrooms and communal areas, which were found to be clean and hygienic with no unpleasant odours detected. The home provided extensive communal facilities including tea bays for resident’s use, assisted bathing, several lounges, a dining room, conservatory, guest room and a laundry. The inspector was told that one of the residents did her own ironing. It was evident that a programme of redecoration and refurbishment was ongoing. The maintenance person had been delegated responsibility for monitoring health and safety within the home. Furnishings, fixtures and fittings were of good quality and domestic in nature. At the time of inspection the garden was being landscaped to provide a solar water feature, seating areas, a Japanese and sensory garden, a lawned area, flower beds and a rose garden. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 14 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 and 30 Residents were being cared for by well trained and knowledgeable staff. Failure to obtain Criminal Record Bureau checks for all staff (including volunteers) placed residents at risk. EVIDENCE: The home had experienced a number of staff vacancies in the period prior to this inspection. Three agency staff were working at the home. The inspector was told that these staff were familiar with the residents as they had worked at the home previously. The home was adequately staffed on the day of inspection and currently recruiting care staff. Appropriate pre-employment checks had been undertaken for permanent staff working at the home. However, two volunteers had been engaged to help with organised activities and these had not been subject to standard Criminal Record Bureau checks. A requirement was made accordingly. 42 of the homes care staff were qualified to NVQ level 2 or above and five members of staff were working towards this qualification. Training records provided evidence of ongoing staff development. Courses in dementia, diabetes and continence care had been undertaken by several staff and mandatory health and safety training was current. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 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 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) 33, 35 and 38 The home operated a responsive service that was committed to making continual improvements based on feedback from residents. Safe accounting systems protected the financial interests of residents living in the home. Failure to ensure secure storage for topical creams placed the welfare and health and safety of residents at risk. Failure to update a risk assessment for one of the residents placed that individuals welfare at risk. EVIDENCE: Internal quality audits were undertaken in the home every six months and two members of staff had received training in this specialism. Additionally, quality surveys were issued to residents, their relatives and visiting health and social Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 16 care professionals on an annual basis. The format for this exercise was being reviewed in response to comments made by residents. The inspector was told that residents’ personal monies were usually managed by the resident or their relatives. The home did hold small amounts of cash for some residents. Accurate records of balances were held, including receipts and all transactions were signed by two members of staff. A safe was provided for the safe storage of residents monies. No environmental health and safety risks were identified during the inspection. However, topical creams were left unsecured in bathrooms. These must be securely held in a locked cupboard. Additionally, a risk assessment for a resident who was prone to falling must be reviewed and brought up to date. Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 17 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 3 x 3 x x 2 Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 18 Yes 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 OP1 Regulation 5 Requirement The Service User Guide must be reviewed and updated to include a reference informing individuals that they can access the most recent copy of the homes inspection report. The homes assessment of need must be reviewed and updated to include the mental health needs of residents. Individual complaints must be recorded separately to comply with the requirements of the Data Protection Act 1998. Stanadard Criminal Record Bureau checks must be undertaken for the two volunteers employed at the home. Secure storage must be provided for all hazardous substances used within the home. The risk assessment for a resident who is prone to falling must be reviewed and updated. Timescale for action 01.09.05 2. OP3 14 01.09.05 3. OP16 22 01.09.05 4. OP29 19 01.09.05 5. 6. OP38 OP38 13 (4) 13 (4) 01.09.05 01.09.05 Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 19 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 Good Practice Recommendations Handsworth Methodist Home F55 F05 s5609 handsworth methodist v227368 010605 stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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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