Inspection on 28/11/06 for Hartford Hey

This inspection was carried out on 28th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hartford Hey 07/08/07

Hartford Hey 27/06/06

Hartford Hey 01/11/05

Hartford Hey 01/07/05

Hartford Hey 09/11/04

Hartford Hey 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hartford Hey Manorial Road South Parkgate South Wirral Cheshire CH64 6US Lead Inspector Maureen Brown Key Unannounced Inspection 28 November 2006 09:30 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 Hartford Hey DS0000006593.V315966.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. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartford Hey Address Manorial Road South Parkgate South Wirral Cheshire CH64 6US 0151 336 4671 0151 336 4671 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) Hartford Hey Limited Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Hartford Hey is a residential care home providing personal care and accommodation for up to 28 older people. It is a family run private business. The home is located in a residential area of Parkgate on the Wirral, near to the river Dee estuary. The home is within walking distance of shops, public houses and other community facilities. There are adequate car parking facilities available. Hartford Hey is two large older style semi-detached houses converted into one. Service user accommodation is on three floors, with access to all floors by a passenger lift or the stairs. There is a newer single storey extension to the rear of the property. There are 22 single and 3 double bedrooms, twelve of which have en-suite facilities. The remaining bedrooms have wash hand basins fitted. The home has extensive patio and garden areas. Some of the bedrooms of the ground floor extension have direct access to the gardens via patio doors. The fees at Hartford Hey are £460.00 per week. Optional extras include hairdressing, chiropody and newspapers. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 28 November 2006 and lasted 8.50 hours. Maureen Brown carried out the visit. An expert by experience was also present. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where “experts by experience” are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term “expert by experience” used in this report describes people whose knowledge about social care services comes directly from using them. This visit was just one part of the inspection. Before the visit the home was also asked to complete a questionnaire to provide up to date information about services at the home. Questionnaires were also made available for service users, relatives and other professionals to find out their views. Other information since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of service users, staff, relatives and visiting professionals were also spoken with and they gave their views about the service. Twenty-four standards were assessed including all the key standards and most were met. Feedback was given to the manager at the end of the visit. What the service does well: The home has an established staff team who were keen for high standards to be maintained. Residents and relatives spoke well of the care given and said that staff were friendly and had an excellent approach. The staff managed activities and entertainments on an adhoc basis and provided a range of activities. Residents said they were pleased with the choices on offer. The expert by experience confirmed that residents enjoyed the activities provided. A good standard of hygiene was seen throughout the home and the standard of décor was acceptable. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: To ensure that residents are cared for, by staff that are trained and competent to do their jobs, mandatory and specialist training in line with residents needs must be continued. 50 of care staff should obtain NVQ level II in Care and the manager must obtain NVQ level IV in Care and Management. To ensure that staff are properly supervised in their role each staff member should receive an annual appraisals. The policies and procedures must reflect current guidelines and be reviewed annually. The policies and procedures should be amalgamated into one filing system for ease of use. To ensure that residents have a choice of meals at each mealtime these should be recorded on the menu board and sheet. To ensure that service users and prospective service users and their families have up to date information the statement of purpose must be reviewed regularly. To ensure that service users are protected by the homes recruitment policy and procedures pre-employment checks must be carried out, including references, POVA first and CRB checks. Also identity checks should be carried out with regard to all staff members. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 7 To ensure that service users are protected by safe working practices fire drills should be carried out within recommended guidance. Also the individual pages of the accident reporting book should be removed and stored in line with the Data Protection Act 1998. 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. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 8 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 Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 9 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): 1, 2 & 3. Standard 6 was not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient information is provided for residents to make a decision about moving into the home. A pre-assessment document is available to ensure that the home can meet the residents’ needs. EVIDENCE: The statement of purpose and service users guide were produced in individual folders. They included all the information needed to make an informed choice about where to live. Information about the facilities, services provided, fees, terms and conditions of residence was included and the service user guide had a summary of a previous inspection report. Both these documents were well presented and easy to read. A full copy of the latest inspection report was available. The statement of purpose was last updated in December 2003 and contained information regarding the previous manager and National Care Standards Commission. This document must be brought up to date. The service users guide was updated in July 2006. Residents and their Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 10 representatives confirmed that they had received a copy of the service users guide during the initial contact period. A pre-assessment document was available for each service user, which included personal information such as next of kin, medical information, and details of the assessor. Also included was all information required to make an informed decision as to whether the individuals’ needs could be met. The manager confirmed that this was completed during the initial meeting with a prospective resident. Social Services assessment documents were also used by the home to make an initial assessment regarding a prospective service user. Residents and relatives confirmed that the social worker or manager spoke to them about the home and discussed their needs prior to admission. One resident confirmed they were an emergency placement and information regarding the home and their needs were discussed on arrival. Each resident had a contract. Private residents had one produced by the home which stated the terms and conditions of residence. Residents funded by social services had details provided by the funding authority. Residents and relatives confirmed that information regarding fees and any top ups required was given to them by the social worker or the homes manager. Annual fee increases were notified to residents or their family by letter. Two relatives confirmed that they were notified in advance regarding increases in fees. The owner confirmed that fees were calculated annually in June. During the visit the expert by experience discussed with the residents if they were involved in choosing the home. One resident confirmed she had been involved in the process however, some people had come from hospital not seeing the home beforehand. For many the family had made the decision on their behalf and they appeared to be accepting of that. A GP had advised one resident to come to the home to be cared for. One relative informed the inspector that he had looked at fifteen local homes and short-listed five for his mother to view with him. Together they chose Hartford Hey primarily because the warm and welcoming reception they had received on the initial visit. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: A sample of three residents’ care records were seen during this site visit. These were in individual folders, which were well presented and easy to read. Significant progress had been made since the previous visit to develop the care plans. Risk assessments were available for falls, moving and handling, risk of burns from radiators and bathing. Each resident had a visiting professionals sheet that showed visits from GP’s, District Nurses, chiropodist and visits to out patient appointments. Two GP comment cards were received and they stated “they were satisfied overall with the care provide to their patients”. Daily record sheets seen showed day-to-day activities of each resident. They were written clearly, easy to follow and were signed by carers. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 12 Medication records examined showed that this was recorded and administered appropriately. Medication was kept secure. A copy of the British National Formulary dated March 2004 and the Royal Pharmaceutical Society book entitled “ The Administration and Control of Medicines in Care Homes and Children’s Services” were available for reference. Staff confirmed that they received in house training on medication awareness prior to administering medication to service users. During discussions with the residents it was said “the care was very good”, “were well looked after” and “the home had a lovely atmosphere” and “the food is good”. The expert by experience noted that there was a nice atmosphere in the home, relaxed and unhurried with everyone she saw being addressed by name and in a pleasant manner. Residents were taking to each other in the lounges and dining room. Privacy and dignity was maintained and this was covered during staff induction and also covered was independence and quality of life. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities of their choosing. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: A range of activities were undertaken which included reading, bingo, hairdressing, manicures, arts and crafts and watching television. The expert by experience discussed with residents what they liked to do during the day. Residents said that they like to read newspapers, play bingo or watch TV. Some residents confirmed that they liked a bit of a rest in the afternoon. The expert by experience confirmed that residents seemed to like the activities on offer. Activity sheets had been produced for each resident and these were seen on the care plans. It was good to note that activities recorded as preferred by residents were included in the activities provided. The home used an activity diary to show activities undertaken. A variety of activities were documented and these included glass painting, crafts, card making, bingo, DVD/Video afternoons and sing-alongs. Later this week a person selling clothes was visiting the home so that residents could have something new for Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 14 Christmas. It was noted that activities were provided on an ad hoc basis rather than a planned weekly programme. The manager stated that one of the lounges was used as a quiet lounge for people wanting this facility. However, the expert by experience noted that the TV was on in both lounges and confirmed with the residents that they were usually on all day. Visits from family and friends were noted in the daily records. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the lounges or dining area. Relative’s surveys confirmed they were always made welcome by the staff and were offered refreshments. During a tour of the home some bedrooms were seen and these were personalised by the residents with small items of furniture and personal photographs and mementoes. The inspector noted that residents were able to exercise choice over many aspects of their daily life. Whether to join in activities or not; choosing when to get up and go to bed; a choice of whether to eat in company or not and having their own personal possessions within their bedrooms. A four-week rota of menus is provided at Hartford Hey. The expert by experience was invited to join residents for lunch. She noted that there were tablecloths on the tables, napkins and small vases of artificial flowers on some tables. Not all residents had lunch in the dining room. Some residents chose to eat in their rooms and others had gone out for lunch. Residents were offered either water or fruit juice prior to the meal being served, however, no drink was offered to the expert by experience. The main meal was put in front of people and no alternative was offered. The meal was stewed beef, vegetables and potatoes – “Scouse” to the locals. Residents were offered beetroot to accompany this. Some residents commented that this was their favourite meal. The expert by experience noted that her food was cool on the outside and hot in the middle. The flavour was nice and the meat was well cooked. Dessert was treacle sponge and custard. This was just put down in front of people without an alternative, except for three people who had melon. One person asked for custard only. Cups of tea or coffee followed the lunch. Hot and cold drinks are provided throughout the day. Following the feedback from the expert by experience, the inspector discussed the meals with the manager. She stated that the staff knew all the residents liked the meal on offer so no alternative was offered. However, if the main meal is one where some people do not like it for example liver and onions, then an alternative is offered and staff check during the morning who wants which meal. Teatime meals are a choice of soup, sandwiches or a hot snack. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 15 A white board situated in the hallway describes the next meal to be provided. During the morning “beef hot pot with beetroot and treacle sponge and custard” was recorded. However after lunch the evening menu was shown as “soup, sandwiches or sausages and beans”. It was suggested that choices be offered at all mealtimes and that these be noted on the menu board. All appropriate records are kept in the kitchen including fridge temperatures and records of hot cooked foods. The kitchen was seen to be clean and tidy during this visit. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 16 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies are in place to ensure that residents are protected from abuse, neglect and self-harm. Staff are trained in the Protection of Vulnerable Adults. EVIDENCE: The policy on complaints included timescales for any complaint made and information about who else could be contacted, for example the Commission for Social Care Inspection. All relevant paperwork was available if a complaint is received. Neither the Commission nor the home had received any complaints since the last visit to Hartford Hey. Through discussions with residents and relative’s, they were aware of the complaints procedure and who to direct their complaint to. Residents and relatives were confident that the manager would deal with any complaint raised. Residents and relatives had received a copy of the complaints procedure, which is included in the service users guide. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 17 The home had signed up to the Cheshire County Councils’ policy and procedure in line with the “No Secrets” guidance from the Department of Health. A copy of Cheshire’s Social Services policy on Adult Protection was available within the home and was accessible to staff. The manager and staff had attended training on POVA. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 18 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): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and comfortable environment for the people to live in. EVIDENCE: The home was furnished in a domestic style with additional equipment such as grab rails, raised toilet seats and hoists provided as necessary to meet the residents’ needs. An acceptable standard of décor was evident throughout. The bedrooms were all light and airy and had personal possessions and mementos belonging to the residents. The radiators that residents might come into contact with did not have low surface temperatures, however risk assessments had been produced to minimise the risk of burns. The heating and lighting was sufficient throughout the home. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 19 The grounds were well maintained, extensive and secure. Residents said that it was nice to sit out in the good weather and staff confirmed that the seating area was used in the better weather. The expert by experience and inspector both noted that the home was clean, tidy and free from any unpleasant smells. Risk assessments have been carried out and the risks of scalding have been minimised. As a reminder to residents “Hot water” notices have been provided by every hot water tap. An ongoing programme of redecoration was in evidence. The manager confirmed that two bedrooms, corridors on the second floor and a shower room had all been redecorated since the last visit. Also a new carpet had been purchased for one bedroom. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager provided clear leadership. Most records were maintained in a satisfactory manner. Some staff had completed mandatory and specialist training. Service users are not protected by the homes recruitment policy and practices. EVIDENCE: At the time of this site visit the agreed staffing levels were met and confirmed by the staff rota. The owner, manager, cook, domestic staff, laundry staff and maintenance people support the care staff in the care of the residents. The staff team was well established and the team had a range of life experiences and training. Since the previous visit progress has been made in regard of NVQ training. Seven of twenty care staff had obtained NVQ level II in care. One person is currently undertaking NVQ level II and one is undertaking NVQ level III in care. Two people are undertaking NVQ level IV. Some staff confirmed they had completed NVQ training in care. Residents said, “the staff are very good” and “we are well looked after by the staff”. An induction programme was used at the home. During discussions staff confirmed that they had undertaken an induction process. The induction Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 21 process was a basic format but since the last visit it had been reviewed in line with the specification from Skills for Care, which was formally the TOPPS organisation. During this site visit three staff files were examined. Two of the three seen contained most pre-employment checks, including references and Criminal Record Bureau checks. However one file did not have any references, POVA first or CRB. This was discussed with the manager who said this person was employed prior to her starting as manager. However, she would obtain references as soon as possible and POVA first and CRB checks would be undertaken. She stated that she would cover this person’s rota until the references and POVA first check had been confirmed as satisfactory. None of the files contained verification of identity checks. It was suggested that all staff files be examined to ensure that all checks have been carried out. The home had an equal opportunities policy that stated it was committed to equal opportunities for all staff. It stated that equal opportunities would be used in recruitment of staff, recruitment publicity and staff development. Since the previous visit further development of mandatory training had taken place. Most staff had completed training in moving and handling, first aid, food hygiene and health and safety. However, all staff must complete mandatory training. Specialist training in line with the specific needs of the residents should also be undertaken. The manager stated that further training on first aid, food hygiene, diabetes and dementia care was booked over the next few months. Since the previous visit staff meetings had started. A staff meeting had been held on 7 September 2006 where ten staff attended and issues discussed included the CSCI report and training. The last meeting was held on 18 October 2006 and thirteen staff attended. Issues discussed included mandatory training. Records of these meetings were held at the home. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained to influence the running of the home. Service users are not supported by fully supervised staff. EVIDENCE: The deputy manager has been promoted to the manager in July 2006 and is currently applying to become registered with the Commission. She has recently started NVQ IV Registered Managers Award and holds NVQ II in care. The manager has worked at Hartford Hey for thirteen years, four of which in a senior role. During discussions with residents and information received by relatives it was felt the home was well run and that the manager and staff were very Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 23 welcoming and friendly. This was confirmed during the site visit. Relatives confirmed that staff worked in a very friendly manner. Policies and procedures seen were appropriate to the home. However, there were several files with many policies and procedures. It was difficult to know which policies were currently in use. The current policies and procedures must be arranged in one filing system and all other documents kept separately. This remains outstanding from the previous visit, but the timescale has not yet elapsed and therefore the requirement remains. The home had an equal opportunities policy that stated it was committed to equal opportunities for all staff and service users. During discussions with the manager regarding the service users of different faiths she said that she discusses this with them prior to admission to check if she can meet their needs. She stated that often people were now not practicing their faith and therefore did not require or desire any specific religious or cultural needs to be taken into account. The manager stated that the quality assurance process was completed on 1 December 2006 and questionnaires were sent to residents, relatives and visiting professionals. The manager said that a good response had been received. Residents meetings had been reinstated. The first one was held on 6 October 2006 and sixteen staff attended. Any complaints, entertainment and food were discussed. The previous meeting was held on 24 July 2006. Sixteen staff attended. Meals and complaints were discussed and it was recorded that residents were “happy and had no problems”. The manager said that service users were encouraged to keep only a small amount of money on the premises. All residents have a lockable drawer in their bedrooms. The manager holds some money for the residents. This is kept secure in the office. It is in individual wallets with records and receipts kept. Formal supervision had been started following a previous requirement. Discussion regarding the process was undertaken between the inspector and manager. It was agreed that further development is required in this area. This must be completed at least six times a year with records kept. Day to day supervision was seen during the site visit and this was good. It is recommended that annual appraisals be undertaken. The manager stated that during the hand over session of each shift any changes in service users or other issues that arise are discussed. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 24 Fire alarm tests and emergency lighting tests were being undertaken on a regular basis and records kept. A fire risk assessment of the home had been completed and all staff had received training in fire awareness. A fire drill was last completed on 23 February 2004. It is recommended that these be carried out every six months. A visit from the environmental health officer had occurred recently. Gas safety, electrical safety certificates were current and copies of these were available during this site visit. Also seen were up to date records of annual inspections of the hoist and passenger lift. The accident reporting book was seen. It was noted that all records had remained in the book. To keep these records in line with the Data Protection Act 1998, they should be removed from the book and stored securely. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP1 OP29 Regulation 6(a) 19(1)(b) Requirement The registered person must ensure that the statement of purpose is brought up to date. The registered person must ensure all pre-employment checks are carried out, including references, POVA first and CRB checks. The registered person must ensure that policies and procedures are in line with current guidelines and reviewed annually. (Timescale not yet reached). Timescale for action 15/01/07 15/01/07 3 OP33 12 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations The registered person should ensure that residents have a choice of foods at each mealtime and that these are recorded on the menu board and sheet. DS0000006593.V315966.R01.S.doc Version 5.2 Page 27 Hartford Hey 2 3 4 5 6 7 8 9 OP28 OP29 OP30 OP31 OP36 OP36 OP38 OP38 The registered person should ensure that 50 of care staff obtain NVQ level II in Care. The registered person should ensure that identity checks are carried out with regard to all staff members. The registered person should ensure that mandatory and specialist training is continued for all staff as appropriate. The registered person should ensure that a plan is produced to show how the manager will obtain NVQ level IV in Care and Management. The registered person should ensure that annual appraisals are undertaken with the staff team. The registered person should ensure that the formal supervision process is developed. The registered person should ensure that fire drills are carried out within recommended guidance. The registered person should ensure that individual pages of the accident reporting book are removed and stored in line with the Data Protection Act 1998. Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hartford Hey DS0000006593.V315966.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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