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Inspection on 24/05/05 for Hartshead Manor Nursing Home

Also see our care home review for Hartshead Manor Nursing Home for more information

This inspection was carried out on 24th May 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users views and preferences are taken into account when planning menus. Service users spoken to said how good the food is. Service users also said how helpful and kind staff members are, "nothing is too much trouble". Detailed pre admission assessments are carried out for prospective service users.

What has improved since the last inspection?

Care planning has improved. Care plans and assessments were more detailed and up to date. Activities are now provided. A dedicated member of staff organises activities and service users spoken to were pleased with the improvement. Staffing levels are at an acceptable and agreed level, and agency staff are used less often.

What the care home could do better:

Bathrooms must be cleaned adequately and baths kept in a good state of repair. The conservatory ceiling needs to be kept free from cobwebs. Kitchen utensils and equipment which are worn and unsafe should be renewed. Ensure that all staff have up to date training in movement and handling and fire safety. Ensure medication is administered correctly and accurate records held. Repair damaged equipment i.e. fire doors.

CARE HOMES FOR OLDER PEOPLE HARTSHEAD MANOR 817 Halifax Road Hartshead Moor Cleckheaton BD19 6LP Lead Inspector Helen Battle Unannounced 24 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hartshead Manor Address 817 Halifax Road Hartshead Moor Cleckheaton BD19 6LP 01274 869807 01274 852426 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Roche Healthcare Limited Mrs Susan Hoodless CRH(N) Care Home with Nursing 55 Category(ies) of OP Old Age - 55 registration, with number TI Terminally Ill - 5 of places PD Physical Disability - 5 HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 30/09/04 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 formally 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. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at Hartshead Manor on Tuesday 24th May 2005, and was conducted by two inspectors commencing at 09.05am, and finishing at 2.30pm. Mrs Sue Hoodless the manager was present at the inspection. The following inspection methods have been used in the production of this report: sampling of records, care plans, individual discussion with 8 service users and 5 members of staff, discussion with the management, tour of the premises and document reading. What the service does well: What has improved since the last inspection? Care planning has improved. Care plans and assessments were more detailed and up to date. Activities are now provided. A dedicated member of staff organises activities and service users spoken to were pleased with the improvement. Staffing levels are at an acceptable and agreed level, and agency staff are used less often. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 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 J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5. Service users are assessed before admission. The home’s Statement of Purpose and Service User Guide provide service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: Pre admission assessments were seen for three service users. These were detailed and included information about daily living activities, likes and dislikes and previous medical history. The statement of purpose and service user guide are in place and it was reported that this is sent to new service users prior to admission. A service user said that they had had an opportunity to visit the home before making a choice to live there. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Since the last inspection care planning has improved to adequately provide staff with the information they need to meet service users needs. The systems for the administration and recording of medication are poor and potentially place service users at risk. Personal support is offered in such a way as to promote and protect service users’ privacy dignity and independence. EVIDENCE: Four service user care plans were examined. All were found to contain relevant. Risk assessments were in place which included falls, tissue viability, nutritional status and mobility. There were gaps in monthly reviews for 2 service users for March and April 2005, however these had already been updated in May 2005. This is a marked improvement to care panning at the home and the manager and staff should be commended on the improvement. This must now be maintained. Not all medication checked at the home tallied with the records held. There were gaps in recording medication checked in, brought forward and administered. This is not acceptable and must be addressed quickly. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 10 Service users spoken to stated that they were treated with respect and that their privacy is maintained. One service user stated that they are assisted with their personal hygiene in a manner that respects her dignity. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Good progress has been made in addressing the provision of activities. Contact with relatives and friends is maintained. The meals in this home are good offering both choice and variety and catering for special needs. EVIDENCE: Service users made the following comments in relation to the lifestyle they experience and expectations in relation to recreation. “Staff are kind and pleasant and nothing is too much trouble”. “Staff are very obliging”. “Staff go the extra mile”. “Activities are provided if you want to join in.” Activities include, handicrafts, knitting, bingo, manicures, games, videos and outside entertainers visiting the home periodically. A coffee morning had been arranged, and a garden party is to be held in July 2005. Visitors were observed to be welcomed to the home throughout the day and service users confirmed that their families and friends visit at various times. The atmosphere was relaxed and staff were seen to respond to service users in a kind and caring manner. Service users’ are asked their views and preferences when menus are planned and all service users spoken to stated that the choice and quality of food was very good. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The home has a satisfactory complaints procedure with evidence that service users feel that their views are listened to and acted upon. EVIDENCE: Service users spoken to were confident in speaking to the manager and that any concerns would be addressed. They stated that the manager is very approachable and calls in from time to time to see how they are. Adult abuse and whistle blowing policies and procedures are in place. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21,23,24,25,26 The standard of décor and furnishings within the home is generally satisfactory. The standard of cleanliness and safety in the bathrooms is unacceptable. The standard of cleanliness of the ceiling in the conservatory is unacceptable. EVIDENCE: There was evidence that service user bedrooms are decorated as they become vacant. Communal lounges and dining rooms are decorated to a satisfactory standard. New chairs have been purchased for the conservatory since the last inspection. The ceiling blinds and ceiling in the conservatory were dirty and full with cobwebs. Bathrooms in the home were generally in an unacceptable state. The bath side had fallen off in one bathroom and this bath was chipped in the corner, continence aids were being stored under this bath behind the bath panel. Another bath had black mould on the seal at the side of the bath. The fire door on the staff rooms had been damaged and was no longer safe as a fire door. The laundry floor was lifting and was unsealed in some areas. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 14 HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 After a period of considerable instability in staffing there is now a dedicated staff team offering consistency of care within the home. Staff morale has improved. The lack of training for staff in movement and handling and fire safety potentially places service users and staff at risk. EVIDENCE: Staffing levels have improved since the last inspection. Less agency staff are being used and there is better stability within the staff team. Staffing levels meet previously agreed levels. Recruitment procedures are followed and evidence was seen of satisfactory checks being carried out prior to staff commencing work at the home. NVQ training has increased since the last inspection. Five staff have completed, five are working towards and another six are to be registered as new candidates by the end of May 2005 for NVQ level 2. Movement and handling training is overdue for the majority of staff. The manager has just completed a facilitators update. A fire safety training facilitators course has been booked for three senor members of staff to attend in June 2005. A large number of staff have not received fire training for a long period of time. This must be addressed within the timescale set by the CSCI. Induction training is carried out for new members of staff. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 38 The manager has a good understanding of the areas in which the home needs to improve. Planning was in place and set out how this improvement was going to resourced and managed. There are some concerns regarding health and safety of some equipment in the kitchen. EVIDENCE: The manager of the home is well qualified and demonstrates competence and ability in managing the home. Service users and staff spoken to stated that the manager is approachable, listens and actions any issues which need addressing. All those spoken to appeared to have confidence in the manager. Service users’ personal monies are kept securely and procedures are in place to safeguard these monies. A fridge in the main kitchen had damaged and rusted seals. Chopping boards were worn and baking tins were badly worn and unsafe. The cooker hood in the kitchen was in need of a thorough clean. The rest of the kitchen was clean. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 17 Weekly and monthly health and safety checks are recorded as being carried out as required. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 3 1 x 3 3 3 1 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x x 1 HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13(2) Requirement All medication must be accounted for. Records must be clear and accurate. Staff must be trained in the safe administration of medication. Baths must be cleaned adequately. Baths must be kept in a good state of repair. The ceiling and blinds in the conservatory must be cleaned. The cooker hood must be cleaned. The staff rooms fire door must be repaired or renewed. Staff must receive updated training in movement and handling and fire safety. The identified fridge must be repaired/replaced. The chopping boards must be replaced. The baking tins must be replaced. Timescale for action 3.6.05 2. 3. 4. 21 19 26, 38 23(2)(d) 23(2)(c) 23(2)(d) 24.5.05 3.6.05 3.6.05 5. 6. 7. 19 30 38 23(4)(a) 18 (1)(c)(i) 16(2)(g) 3.6.05 31.7.05 10.6.05 HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 20 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 26 Good Practice Recommendations The laundry floor should be impermeable and readily cleanable. HARTSHEAD MANOR J51J01_S1085_Hartshead Manor_V229170_240505.doc Version 1.30 Page 21 Commission for Social Care Inspection 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. 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