This inspection was carried out on 27th March 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.
CARE HOMES FOR OLDER PEOPLE
Hartcliffe Nursing Home Murford Avenue Hartcliffe Bristol BS13 9JS Lead Inspector
Jon Clarke Unannounced Inspection 27th March 2006 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 Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hartcliffe Nursing Home Address Murford Avenue Hartcliffe Bristol BS13 9JS 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) 0117 9641000 66 home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Ruth Andrews Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (10) of places Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. May accommodate up to 66 persons aged 65 years and over requiring nursing care May also accommodate up to 10 persons with physical disability under the age of 65 requiring nursing care 17th August 2005 Date of last inspection Brief Description of the Service: Hartcliffe Nursing Home is owned by Methodist Homes for the Aged and provides nursing care for up to sixty-six older people and 10 persons with physical disability under the age of 65 requiring nursing care. It is located in a suburban position and can be accessed by public transport. Transport is needed to reach local shops and amenities. The home itself is purpose built and has now been in operation for 5 years. 64 bedrooms are for single occupancy and there is one double room. They are set out over two floors accessible via the passenger lift. Communal space is offered in 4 lounges and there is a spacious dining room on each floor. There is a small garden and parking spaces for visitors. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day; the manager was present during the inspection. The focus of this inspection was to examine standards not looked at on the previous inspection and review requirements made from the previous inspection. As part of this inspection a number of records were looked at including care plans, training, health and safety. There was also an opportunity to discuss with residents their experience of living at Hartcliffe. What the service does well: What has improved since the last inspection?
A number of requirements were made from the previous inspection these have all been met resulting in changes in recording of social needs, replacement of carpeting and addressing arrangements regarding activities. Since the last inspection an activities organiser has been recruited and it is hoped this will result in an improved level of activities in the home. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 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. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was looked at on the previous inspection. A requirement was made to amend the State of Purpose this was done and the standard is now met. EVIDENCE: Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Individual care plans provide the required information about health and social care needs so that staff can provide the care needed by residents. Standards 8,9,10 were all met at the previous inspection. EVIDENCE: Care Plans were looked at and showed care needs and associated tasks. A requirement regarding including social needs had been addressed and these were included in 3 plans, which were examined. In one instance a relative had provided information about the interests, likes and dislikes of a resident who has dementia and was not able to provide this information. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The practices of the home help residents exercise choice and make decisions about their daily lives. EVIDENCE: In discussion with a number of residents they confirmed that they felt able “to choose how I spend my day” one resident said they dint “feel I have to do anything which I don’t wont to its up to me”. When asked about daily routines such as getting up and going to bed residents said that they felt “it was up to me” another “I decide what is best for me”. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Standard 16 was looked at on the previous inspection and was met. The arrangements for protecting residents from abuse could be improved by the provision of training to all staff to provide the necessary knowledge and skills to identify potentially abusive situations. EVIDENCE: In discussion with the manager it was identified that whilst there is a whistle blowing policy all staff have not undertaken Adult Protection training. In addition the manager has not completed training organised by the local authority, which would provide her with the knowledge of local policy and procedure. However it was noted that prior to this inspection the manager had acted appropriately when addressing a potential abusive situation. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 were looked at on the previous inspection and were both met. EVIDENCE: Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 The staffing arrangements help to make sure the needs of residents are met. The recruitment policy and procedure and training arrangements ensure that residents are protected and that staff are competent to undertake the tasks and responsibilities required. EVIDENCE: Staffing rotas were looked at and showed that there is sufficient staff on duty to meet the needs of residents. The rotas for a period of 6 weeks were examined: a RGN is on duty at all times with addition of 4/5 care staff on both floors of the home with waking night staff. Care Assistants undertake NVQ 2, currently over 50 staff have NVQ qualification. Recruitment records illustrated that the required practice is undertaken with full employment history, references. For staff that are recruited from overseas police checks are obtained and work permits were seen as being in order. The home has good arrangements for the training of staff with extensive specialist training this is to be commended. Included are Nutrition In Older People, Mental Health Awareness, and Infection Control. A number of staff have recently undertaken Palliative Care and Care of the Dying training. This the manager believed has led to a more informed practice particularly in supporting relatives on the death of a relative. The home also has links with the University of the West of England in providing training. In examining staff training records it was noted that a high number of staff had not completed
Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 14 Moving & Handling training this was discussed with the manager who advised that training was planned for the near future. Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The health and safety practices of the home ensure that the welfare of residents and staff is protected. Standards 31,33,35 were looked at on the previous inspection and were met. EVIDENCE: Records relating to health & safety were seen and illustrated good practice in meeting the requirements to maintain fire system last service 3/06, fire alarms tested weekly as is emergency lighting, door release closures. A risk assessment has been undertaken of the homes environment to identify potential areas of fire. Staff undertake fire drills on a regular basis. Equipment is maintained last service hoists and parker bath 9/02/06. gas safety certificate issued 29/03/05. Lift Inspection 8/03/06. It was noted that the maintenance man has a through and conscientious approach to his duties.
Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 16 Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 18 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 OP30 Regulation 18 (1a,c) Requirement Ensure all staff undertake Adult Protection training this to include senior staff to complete local authority Investigators course. Ensure all staff undertake moving and handling training within reasonable period of commencement of employment. Timescale for action 30/07/06 2 OP30 18 (1a,c) 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hartcliffe Nursing Home DS0000031895.V283727.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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