Inspection on 23/10/07 for Hartshead Manor Nursing Home

This inspection was carried out on 23rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 11/10/06

Hartshead Manor Nursing Home 01/11/05

Hartshead Manor Nursing Home 24/05/05

Hartshead Manor Nursing Home 30/09/04

Hartshead Manor Nursing Home 20/04/04

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Snydale Care Home

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Larchfield Manor

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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 Helen Battle Key Unannounced Inspection 23rd October 2007 09:20 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.V353568.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. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 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 hartsheadmanor@rochehealthcare.com 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.V353568.R01.S.doc Version 5.2 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. 11th October 2006 Date of last inspection Brief Description of the Service: Hartshead Manor provides care and nursing for up to 55 elderly people of either gender. It was converted into a nursing home in 1989. It has many of the original features and it was formerly the manor house to Hartshead Moor, the original building dating back to Georgian times. There are gardens with open lawns that provide a level area of some 3 acres, easily accessible by foot or by wheelchair. The orchard and walled area have been preserved to provide shade in the summer from the sun and a sitting area when weather permits. The home is near to the major cities and towns of Leeds, Bradford, Halifax and Huddersfield, however it is set in a rural village offering all essential amenities. There are adequate parking facilities within the grounds and public transport is accessible, with bus stops located within five minutes’ walking distance from the home. The Provider informed the Commission for Social Care Inspection on 23rd October 2007 that the fees range from £393.12 to £624.00 per week. There are additional charges for hairdressing, newspapers, magazines, chiropody and aromatherapy. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, an unannounced visit to the home took place. The inspector visited the home from 09.20 hrs to 15.00 hrs. Whilst at the home, key documents that give information about how people are looked after and how the home makes sure staff are fit to work at the home were looked at, and so were all the rooms and garden. Three members of staff were spoken with. Before the visit, the manager was requested to provide CSCI with information about the people who live at Hartshead Manor, the staff that work there and any incidents or accidents that have happened there since the last inspection. This was returned to the Commission prior to the visit taking place. This information has helped form the judgements made about how the home is performing. Surveys were sent out to ten people who live in the home, their relatives, and to people’s doctors and social workers. At the time of writing this report, five responses had been received from people living in the home, six relatives and one response from a GP. Feedback from the people living in the home was positive and comments included: Very good care and support, staff very nice. Meals are good but the quality varies depending on different cooks. Staff are very caring. I enjoy a good quality of life. Comments from relatives included: Feels like home from home. Staff welcome you each time you visit regardless of how many times you go. There is just a feeling of well-being and goodwill amongst the staff. Nothing is too much trouble for them. They create a warm and friendly atmosphere. My relative is treated with respect and her dignity maintained. Staff are marvellous. My relative has a limited ability to take part in activities but I feel she is included. Two relatives said that they would recommend the home to anyone. Particular praise was given regarding the manager of the home, Sue Hoodless. Comments included that she is a wonderful role model, charming, professional caring, nothing is too much trouble for her – her demeanour obviously rubs off on staff who are the best! Comments were also received regarding improving lighting in lounges and corridors and blinds in conservatory. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 6 The inspector would like to thank the people living in the home, the staff and manager for their warm welcome, hospitality and co-operation during this visit. What the service does well: What has improved since the last inspection? Automatic closures have been fitted to most doors to ensure the safety of people living in the home in the event of fire. Two new baths and a shower room have been fitted to improve facilities for people. The majority of bedrooms have been redecorated and new furniture purchased for bedrooms and the conservatory. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hartshead Manor Nursing Home DS0000001085.V353568.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 Hartshead Manor Nursing Home DS0000001085.V353568.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): 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: The care records of three people living in the home were examined and all were found to have appropriate community care assessments, which are carried out by Social Services, prior to admission and provided the information the home needed about these people. The home also carries out their own assessment of people prior to confirming whether their needs can be met at Hartshead Manor. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 10 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The level of care people need, which includes their health, personal and social care needs, are clearly highlighted within their care plan. Medication is managed well. EVIDENCE: The care plans of three people living at the home were examined. These were clear documents, which included assessments to identify whether individuals are at risk of falling, need help to move about the home, developing pressure sores or having problems eating and drinking. The daily records examined were sufficiently detailed in their content, however the records relating to the social life and activities people take part in were not always fully documented. The people living at the home on the day of this visit, looked well cared for, comfortable and relaxed. People responded well to the staff and it was evident from observing staff interaction with people living in the home that they knew each individual’s likes, dislikes and needs. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 11 Feedback from people living in the home and those spoken to on the day of this visit was positive. People said that staff are kind, pleasant and approachable, and they were able to have a laugh and a joke with them. The healthcare needs of people are met. Evidence was seen of involvement from people’s doctors, opticians, dentists and other healthcare professionals where needed. Specific detail was provided in relation to wound care. There was a clear picture of the date and condition of any wound each time nurses assessed it. The care plans in relation to wound care were very good. Staff should be commended on this aspect of care and care planning. The medications of three people were checked and all were found to tally with the records held. Medications are stored appropriately and a staff signatory list is in place to ensure that it is clear who has administered medications. During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 12 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The lifestyle at the home satisfies the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: An activities co-ordinator is employed at the home and has held this post for some time. She evidently knows the people living in the home well and what their likes, dislikes and abilities are regarding how they like to spend their time. A record of previous hobbies and interests are documented after speaking with families and friends. Activities provided have included bingo, games, quizzes, outside entertainers, movement to music, videos on a large screen television and manicures. Trips out have also been arranged and a small group of people recently went on a barge trip which they spoke about enthusiastically. People living in the home did comment that trips out have been difficult in the recent months due the minibus provided by the company being out of action. This issue was raised with the manager who said that a replacement minibus was to be in place during the week following this visit. This was fed back to the people who raised this query during the visit. Plans are already underway for the Christmas Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 13 period with people living in the home speaking about the plans for two parties so that families and friends can join in the festivities. Lunch was seen being served during this visit and people appeared to be enjoying a meal of chicken casserole, mashed potato and peas followed by fruit sponge and custard. This was nicely presented and people were being assisted to eat their meal, where required, in an appropriate manner. The atmosphere was relaxed and unhurried. A variety of drinks were offered to people throughout the meal. People living in the home said that the meals are always nice and that staff go round and ask them what they would like from the menu for the following day. Contact is maintained with families and friends. Relatives were seen to visit the home during this visit and were seen to be made welcome by the staff. People are encouraged to exercise control in their day-to-day lives where possible. Resident/relative meetings are held six monthly. Recently a residents committee has been started and this has proved to be successful. Two committee members were spoken to and discussed their role, emphasising that they feel they are making a difference to the daily lives of the people living in the home. Minutes of the committee meetings are taken and these were seen during the visit. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People can be confident that their complaint will be dealt with effectively. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that the people they support are safe. EVIDENCE: The complaints procedure is displayed in the entrance area to the home. Feedback from people spoken to indicated that they and their families know who to speak to if they have any concerns. A complaints log is kept and an audit of complaints is carried out monthly by the manager of the home. The log was examined and complaints received were seen to be appropriately investigated and responded to within the required timescales. It is positive that the manager view complaints as an opportunity to improve the service they provide for people. Three quarters of the staff team have received training regarding safeguarding (adult protection) this year. There are further dates set within the weeks following this visit for the remainder of the staff to attend. Staff spoken to on the day of the inspection showed a good awareness of adult protection issues and procedures. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is safe and maintained and the standard of decoration and furniture in the home is good. The home is clean and there were no unpleasant odours. EVIDENCE: The environment of the home is maintained to a good standard. When a room becomes vacant it is redecorated. All the communal areas are light and easily accessible for service users to walk in. Furniture is of a good standard. The home was clean and free from unpleasant odours during this visit. The downstairs lounge carpet appeared to be heavily stained and needs replacing. The plans to replace a bathroom with a shower room have now been completed and it was reported that this facility has been beneficial for the people living in the home. Two new baths have also been fitted in the home. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 16 These bathrooms are now in need of decorating, as they look worn and shabby. The works to extend the laundry have yet been commenced. A decision needs to be taken to set a date for this, as the laundry floor remains an issue, as it is not safe and hygienic. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People’s needs are met by trained and qualified staff who have undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: Staffing levels provided at the home are sufficient to meet the needs of the people living in the home. Generally in the morning there are two nurses and 8 care assistants; in the afternoon there are 2 nurses and 7 care assistants; and at night there is 1 nurse and 4 care assistants. These levels must be maintained due to the dependency levels of the people living at the home and due to the layout of the building. The recruitment records for three members of staff were examined. All were found to have the required checks and references in place prior to the member of staff commencing work in the home. Induction training is comprehensive. The “Skills for Care” Common Induction 12 week course is followed. Completed workbooks were seen during this visit. Mandatory training provided includes movement and handling, health and safety and fire training. Other training staff have attended, or are due to attend, includes infection control, basic food hygiene and “Under Pressure” (Training in the care and prevention of pressure sores). Dates are set for staff Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 18 to have their second fire safety update before the end of November 2007. Dementia care training is to commence for some of the staff in the near future. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 19 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, 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is well managed, people are kept safe by health and safety practices; they are involved in making improvements as part of the home’s quality assurance system. EVIDENCE: The manager of the home is an experienced nurse who is able to discharge her duties fully and effectively manages the home. The people living in the home benefit from the management approach at the home, where their best interests are kept in mind with any decisions that are made. People living in the home, relatives and staff gave positive feedback about the manager, saying that she is always approachable and always sorts things out. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 20 The personal monies held in the home for three people were checked as part of this visit. All were found to tally with the clear records held. Receipts for purchases are also kept. Staff generally receive supervision every two months. Tests of the fire alarm and emergency lighting system are recorded as being carried out weekly. Fire drills are also carried out periodically. Hot water temperatures are checked and recorded as required; any remedial action taken is also recorded. Since the last visit, the majority of doors have had appropriate magnetic closures fitted which are linked to the fire alarm system. It was observed that a small number of doors were still being wedged open. These were in areas where there is always a member of staff nearby during the day and these doors are closed at night. Enquiries are being made to locate automatic closures to fit these doors, as there is a problem in fitting the type fitted to other doors. There are robust quality monitoring systems in place for each area of the home. Surveys are sent out to relatives periodically and the results published. Monthly management visit reports are completed every month as required. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 21 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 X 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 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP26 OP19 Good Practice Recommendations The laundry floor should be made impervious. Consideration should also be given to replacing the carpet in the downstairs lounge. The bathrooms should be decorated. Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Hartshead Manor Nursing Home DS0000001085.V353568.R01.S.doc Version 5.2 Page 24 - 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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