Inspection on 01/11/05 for Hartshead Manor Nursing Home

This inspection was carried out on 1st November 2005.

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.

Other inspections for this house

Hartshead Manor Nursing Home 14/10/09

Hartshead Manor Nursing Home 23/10/07

Hartshead Manor Nursing Home 11/10/06

Hartshead Manor Nursing Home 24/05/05

Hartshead Manor Nursing Home 30/09/04

Hartshead Manor Nursing Home 20/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Hartshead Manor Nursing Home 817 Halifax Road Hartshead Moor Cleckheaton West Yorkshire BD19 6LP Lead Inspector John Gregory Unannounced Inspection 1st November 2005 08:00 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 Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hartshead Manor Nursing Home Address 817 Halifax Road Hartshead Moor Cleckheaton West Yorkshire BD19 6LP 01274 869807 01274 852426 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) Roche Healthcare Limited Mrs Susan Hoodless Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55), Physical disability (5), Terminally ill (5) of places Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can provide accommodation and care for two named service users under 65 years From time to time the home is able to admit service users between the ages of 60 and 65 years, to a maximum of five in the home at any one time. 24th May 2005 Date of last inspection Brief Description of the Service: Hartshead Manor is a care home providing personal care, nursing and accommodation to 55 persons experiencing issues related to aging. The service is owned by a limited company that also owns other homes in the district. The accommodation is an adapted and extended Georgian property in its own grounds at the confluence of the towns of Huddersfield, Halifax and Bradford. The accommodation is built over two floors that are linked by two passenger lifts. The bulk of the accommodation is for single occupancy with en-suite facilities. There are lounges on both floors and a dining room on the ground floor. Large grounds surround the building with good car parking facilities available. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which took six hours, was unannounced and took place during the course of one day in November 2005. The fieldwork concentrated on the standards that the CSCI determine are central to the care process. A sample of policies, procedures and records were examined that were relevant to the standards inspected. Six case files were examined, 2 of which were examined in more detail. Interviews were held in private with six service users. Six staffing files were examined and private interviews were held with five staff. A brief tour of the accommodation was undertaken. The home’s manager, who also received the verbal feedback, assisted the inspector throughout the inspection. The inspector would like to thank the service users, staff and manager for their time, co-operation and hospitality during the course of the inspection. What the service does well: What has improved since the last inspection? The service provider has taken action to address all the issues raised at the last inspection. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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 Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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): 3 All service users are admitted after a full assessment and an assurance by the home that their needs can be met. EVIDENCE: The six service users’ files examined all contained evidence of a full preadmission assessment having taken place by the home’s manager and, in some cases, under the care management arrangements. The files also contained evidence of a letter being sent to the service user confirming the home’s ability to meet their needs. Few service users interviewed could recollect the detail of the admission process but were happy that their needs were being met. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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): 7,8,9 & 10 The service user needs are fully set out in care plans, which are regularly reviewed in order that they remain relevant to their care. The service users’ health care needs are met. The home’s medication system protects service users although some attention to detail is required. The manager is to be commended for the way care is based in the privacy of the service users’ own rooms and their dignity is protected. EVIDENCE: The six care files examined all contained evidence of full care plans and risk assessments that were reviewed monthly by the senior staff. Service users confirmed that they were aware of the plans and involved in their development. Risk assessments were undertaken on a wide range of physical risks including the risk of falls. Service users were able to confirm that they had kept the same General Practitioner that treated them prior to their admission. File notes confirmed the Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 10 involvement of the primary health care team and other medical ancillaries. Service users were happy with the medical care they received. The medication system was basically robust and protects service users. It is based on the monitored dosage system. All medication is safely stored. On audit it was noted that initials rather than full signatures were sometimes used in the controlled drugs register. Commendably, the care in the home is based on the service users’ own rooms where, from choice, the majority spend the bulk of the day. Transactions between staff and service users were observed to be positive and service users were unanimous in their appreciation of the way staff cared for them. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 & 15 There is a good range of activities from which service users may choose their particular lifestyles. The visiting arrangements are open. Choices are available to the service users in most area of their life. There is a good choice of nutritious meals served in the location of the service users’ choice. EVIDENCE: The service provider employs a part time activities coordinator who provided both group and individual activities. The range of activities is publicised and the service users were aware of the activities and became involved as they chose. Visitors were seen in the home throughout the inspection and service users confirmed that they could receive visitors at any time. There was evidence on file of relatives continuing to be involved in the service users’ care whilst they are resident in the home. Service users described their choice of food, involvement in activities and ability to retain their own money and medication. All the service users’ rooms seen contained evidence of personal possessions having been brought into the home. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 12 The menu and record of food served contained evidence of multiple choices of nutritious food. The service users interviewed were all happy with the food and choices available to them. The meals are served, in the main, in the service users’ own rooms although some service users confirmed the inspector’s observation that they choose to eat their meals communally. Some service users were observed being assisted with their meals in a discreet and sensitive manner. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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 the following standard(s): 16 & 18 The complaints system is robust and has the confidence of service users. The service users are protected from abuse. EVIDENCE: The service provider has a robust complaints procedure that is understood by staff. Service users were confident that any concern would be taken seriously by staff and rectified. There had been four complaints since the last inspection all of which had been effectively addressed within the relevant time frames. The service provider has a procedure for the prevention of abuse to adults. Its ability to protect service user would be enhanced by it containing better links to the local joint agency procedure. The staff had a good understanding of this procedure and that of whistle blowing. The manager’s system for using and reviewing bedsides is comprehensive and protects service users. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 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 the following standard(s): 19 & 26 The service users live in a safe, well-maintained environment to which minor attention is needed. The home is pleasant, domestically furnished and decorated. Hygiene would be enhanced by attention being paid to the laundry floor. EVIDENCE: On an inspection of the home it was noted to be basically well maintained, domestically furnished and decorated. This impression is diluted by the extent of wheelchair damage to the skirting boards doorways and decoration in the corridors, which needs attention. Rooms were light and airy and had facilities appreciated by the service users. The laundry was well equipped with commercial equipment capable of sluicing and is run by designated staff. The impervious floor to the laundry is compromised by incomplete coverage and needs attention to protect hygiene arrangements. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 numbers of staff are sufficient to provide dignified private care to service users. The recruitment process is sound but protection for service users would be enhanced by more complete information being undertaken prior to appointment. Staff are committed well liked by service users and trained in the basics of care provision. EVIDENCE: The staffing is based on ten caring staff on duty in a morning, 9 staff in an afternoon and 5 waking night staff including nurses. A good level of domestic, kitchen and laundry staff supports this staffing level with other ancillary support. The recruitment process is, in the main, good but would be enhanced and service users better protected by the service provider consistently obtaining a POVA check prior to appointing staff. Service users hold the staff in high regard and they impressed on interview as committed and hard working. All the staff confirmed that they had recently received training in matters related to the health and safety of service users. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 16 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): 33,36 & 38 The service provider needs to develop and act upon a Quality Assurance programme to ensure that the home is run in the best interests of service users. The systems to ensure that staff are appropriately supervised need development. The health and safety of service users and staff are promoted and protected. EVIDENCE: The manager reported that the service provider has a formal Quality Assurance system however there was no evidence to support the fact that it has been operated in recent times to ensure that the home is run in the best interests of service users. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 17 The manager has developed a supervision process to assist in the development of staff however this is not yet operational at a frequency that will have a significant effect. The service provider has a complete set of policies, procedures and records to ensure that the health and safety of service users and staff are protected. The staff and service users felt safe living and working in the home. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 18 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 2 X 3 Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 19 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 OP33 Regulation 24 Requirement The service provider must establish and maintain a system for reviewing at appropriate intervals; and improving the quality of care provided in the care home. Timescale for action 01/04/06 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 2 3 4 Refer to Standard OP9 OP19 OP26 OP36 Good Practice Recommendations Two full signatures in the controlled drug register should confirm the administration of controlled drugs. The damage to skirting boards and doorways in the corridor should be made good and redecorated. The laundry floor should be made impervious. All staff should receive supervision six times a year. Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hartshead Manor Nursing Home DS0000001085.V261139.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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