CARE HOMES FOR OLDER PEOPLE
Harehills Burnfoot Way Kenton Newcastle upon Tyne NE3 5TL Lead Inspector
Anne Brown Announced 10 August 2005 9:30 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. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Harehills Address Burnfoot Way Kenton Newcastle upon Tyne NE3 4TL 0191 285 2832 0191 284 0773 simeon.mulligan@newcastle.gov.uk Newcastle City Council 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) Mr Simeon Mulligan CRH 30 Category(ies) of DE(E) Dementia - Over 65 - 8 registration, with number OP Old age - 22 of places Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Up to 3 beds can be flexibly used to accommodate service users aged 55 to 64 years old, or service users over pensionable age. Date of last inspection 2/3/05 Brief Description of the Service: Harehills Resource Centre is a registered care home that provides respite/short stay care to older people and older people with dementia. The home is located in Kenton, Newcastle Upon Tyne. Accommodation is over two floors and a passenger lift is provided. There are a variety of communal lounges and dining rooms throughout the home and a patio garden is accessible to the service users. There is access by public transport. Local amenities and shops are not within easy walking distance. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and took place over seven hours. A partial tour of the premises took place and a sample of care records were inspected along with the fire log book, accident book, maintenance contracts, complaints and compliments and minutes of meetings held in the home. Discussions were held with the manager and six members of staff. The majority of service users were seen and conversations were held with nine service users and two visitors. Five questionnaires were returned by the service users and one was returned by a relative. What the service does well: What has improved since the last inspection?
Requirements made at the last inspection have been completed. Since the last inspection the main dining room, main lounge, smoking lounge and five bedrooms have been redecorated and new bedding and curtains provided.
Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 6 A representative from the home has been designated to liaise with the Communicable Disease Unit to ensure the staff team are kept updated regarding infection control procedures. The staff continue to develop a programme of meaningful activities which suit the individual service users. 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. Harehills B53-B03 S33620 Harehills V233337 100805 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 Harehills B53-B03 S33620 Harehills V233337 100805 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) 2, 3 and 5. The service users and/or their representatives are fully aware of the terms and conditions of their stay in the home. Detailed pre-admission assessments are carried out and where possible new service users are invited to visit the home prior to admission to whether the home can meet their needs. EVIDENCE: Statement of terms and conditions were available on the case files. These documents are signed by the service users but not all sections had been completed by the staff. All admissions are made through a single entry point referral process. Six case files were examined and all contained a full needs assessment carried out by appropriately trained people. On the day of the inspection two visitors were visiting the home to assess whether it would be suitable for their relative. Harehills B53-B03 S33620 Harehills V233337 100805 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. The care plans include all the necessary information that helps ensure that the staff team are well informed about the needs of the service users. The service users’ privacy and dignity is respected. The medication procedure and system were appropriate. EVIDENCE: Six care plans were examined and were up to date. They contained detailed information about the personal, health and social needs. Some care action plans had not been signed by the service users to confirm they have been fully involved in their development. The staff team on duty were observed to be aware of the needs of the service users and were communicating with each other at the end of the shift to ensure any problems were highlighted. The service users confirmed that the staff respect their privacy and dignity at all times. Members of staff were observed to be treating the service users with respect throughout the inspection.
Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 10 The medication system and a random sample of records were examined. These were in accordance with the pharmacy guidelines, apart from one record of medications returned to the service user upon discharge, had not been signed. Lockable facilities are provided in the majority of bedrooms although one service user who administers her medications did not have this facility. Harehills B53-B03 S33620 Harehills V233337 100805 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 and 15. A wide range of activities take place in the home that cater for the individual preferences of the service users. Family and friends are encouraged to visit the home and links with the community are maintained. Menus are varied and nutritional. A choice is always available. EVIDENCE: A list of activities taking place in the home was displayed in the dining rooms. These include bingo, hand care, crafts, gardening, quiz, reminiscence, sing-along, card, dominoes and entertainers. The service users can also participate in activities taking place in the day centre attached to the home. A mini bus used to transport service users to and from the day centre is also sometimes available for trips to local places of interest. One service user was enjoying walking around the garden. Some ladies were enjoying a manicure sessions with the staff during the inspection. Some service users stated that they preferred to spend time in their bedrooms rather than join in the activities. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 12 A number of visitors were visiting during the inspection. Some were observed to be visiting their relatives in their bedrooms. One gentleman said a member of staff was to escort him to see his GP on the afternoon of the inspection. Four weekly menus are in place and these are reviewed on a regular basis. The staff were observed to be consulting the service users about their choice of meal prior to lunchtime. The food was well presented and the portion sizes were ample. The meal was relaxed and unhurried and the staff were sensitive to the service users’ needs. The dining room tables were appropriately set with condiments and napkins. The service users confirmed that they enjoyed the food served in the home and drinks are available throughout the day and night. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system in place. Residents are protected from abuse. EVIDENCE: A suitable complaints procedure is in place and complaints leaflets are displayed in the foyer area of the home. One complaint has been received by the home since the last inspection. This has been investigated by the manager and satisfactorily resolved. The complainant declined to make an official complaint to the Local Authority. Compliments are displayed on the notice board in the home. Policies and procedures for the protection of vulnerable adults are in place and the staff were aware of the procedure to follow if they felt abuse was taking place. The manager confirmed that existing staff team have received formal training on the protection of vulnerable adults and new staff members have been booked on the course. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23 and 26. The home is well maintained, safe, homely and comfortable. Communal areas and bedrooms are well decorated and furnished. A pleasant garden is available and this is attractive and accessible. All areas are clean and hygienic. EVIDENCE: On the day of the inspection the home was welcoming, clean and well maintained. The home is divided into two units and each has its own lounge and dining areas. The bedrooms were pleasantly furnished and decorated with coordinated bedding and curtains. An unpleasant odour was apparent in one vacant bedroom. The manager has ensured this bedroom is closed until the problem is resolved. No health and safety hazards were noted. Communal areas were pleasantly decorated and furnished. An attractive patio area is accessible where service users can sit and tend to the flower tubs if they choose.
Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 15 Since the last inspection the main dining room, main lounge, smoking room and five bedrooms have been redecorated. The paintwork on the door frames in the corridors was showing signs of wear and tear. One member of staff has been nominated to be the contact person with the Communicable Diseases Unit and will cascade any necessary information to the staff team regarding infection control measures. Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 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 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 and 30 Staffing levels in the home are adequate and the manager ensures the staff team are trained, skilled and competent to do their jobs and to meet the needs of the service users. The staff team are committed to offering a high standard of care to the people using the service. EVIDENCE: Staff rotas were examined and showed that staffing levels are being maintained. On the day of the inspection there were adequate numbers of staff on duty to deal with the needs of the service users. The staff confirmed that they received regular mandatory training and specialist training to deal with the individual needs of the service users. They were observed to be caring with the service users in a competent and sensitive manner. Good relationships were observed throughout the home. The service users stated that the staff were very helpful and friendly. One questionnaire returned by a service user stated ‘the staff and food are the best’. One relative stated ‘I have nothing but praise for the care my father received’. A comment was made that the staff were friendly and courteous. Harehills B53-B03 S33620 Harehills V233337 100805 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) 32, 33 and 38. The home is well run by a competent manager for the best interests of the service users and staff are well supported. Health and safety of the service users is promoted by well trained staff and appropriate risk assessments are in place. EVIDENCE: Service users are consulted in all aspects of the day to day running of the home and this information is recorded in minutes of meetings. An action sheet is produced to ensure all issues raised are followed up. Questionnaires are issued to service users at the end of each stay. No formal quality assurance system has been introduced to monitor the services provided. The staff on duty confirmed that the manager is supportive and approachable.
Harehills B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 18 The staff receive regular training in health and safety issues and all accidents are recorded and monitored on a monthly basis. Risk assessments are carried out on the premises by staff in the home on a regular basis. Copies of up to date maintenance certificates were not available for the gas installations, hoists, passenger lift and emergency lights. The manager stated that these would need to be obtained from the Civic Centre but confirmed the tests had been carried out. No health or safety hazards were observed during the inspection and staff sign to confirm they receive regular fire instruction. Harehills B53-B03 S33620 Harehills V233337 100805 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 x 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 3 x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 2 x x x x 2 Harehills B53-B03 S33620 Harehills V233337 100805 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. 2. Standard 2 7 Regulation 5(3) 15(1) Requirement All sections of the terms and conditions and residency must be completed by staff. All service users and/or their representatives must sign the care action plan to confirm they agree with the care to be provided. Staff must sign for any medications returned to the service users at the end of their stay. Lockable facilities must be provided in all bedrooms for the safekeeping of medications. Copies of maintenance safety certificates must be forwarded to the CSCI. Timescale for action 19/8/05 31/8/05 3. 9 13(2) 19/8/05 4. 38 23(2)c 31/8/05 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. 2. Refer to Standard 19 33 Good Practice Recommendations Renew paintwork on door frames in corridors. Quality Assurance and Monitoring system to be introduced to the home.
B53-B03 S33620 Harehills V233337 100805 Stage 4.doc Version 1.30 Page 21 Harehills Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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