Inspection on 02/08/05 for Hartsholme House

This inspection was carried out on 2nd August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hartsholme House 13/11/06

Hartsholme House 24/02/06

Hartsholme House 07/02/05

Hartsholme House 11/08/04

Hartsholme House 08/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hartsholme House Ashby Avenue Hartsholme Lincoln LN6 0ED Lead Inspector Elisabeth Pinder Unannounced 2 August 2005 @ 08:40 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. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hartsholme House Address Ashby Avenue Hartsholme Lincoln LN6 0ED 01522 683583 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) The Order of St John Care Trust Mrs J Luke Care Home Only (PC) 42 Category(ies) of Dementia - Over 65 years of age (DE(E)) - 7 registration, with number Old Age, not falling within any other category of places (OP) - 35 Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 07.02.05 Brief Description of the Service: Hartsholme House cares for older people needing personal care with seven places specifically registered to care for people with dementia. The home is a detached property surrounded by gardens and is situated in a residential area to the south of the historic city of Lincoln. Car parking is available at the front of the building and local facilities include shops, library, post office and church. Transport is required to access the main city and is provided at no extra cost. The home has two floors and there is a passenger lift to the bedrooms on the first floor. There is a variety of aids and adaptations around the building to allow residents to move around the home more independently. All of the bedrooms are single, none have ensuite facilities. The home is one of 16 operated by the Order of St John Care Trust, which is a Registered Charity. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours and was carried out by one inspector as the first of two statutory inspections for 2005/6. The main method of inspection used was “case tracking”. This involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. It also included a general discussion with other residents. One bedroom was viewed and a selection of care records inspected. What the service does well: What has improved since the last inspection? What they could do better: A review of staffing levels and deployment should be undertaken to ensure sufficient staff are available during the night time to meet the needs of residents. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 6 The health and safety of residents and staff could be improved by the addition of an enclosed sluice. Consideration should be given with regards to setting up meetings for relatives and representatives of residents. 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. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 Standard 6 does not apply as the home does not provide an intermediate care service. This home provides residents with detailed information enabling them to make an informed choice about coming to live in this home. Residents are admitted only after a full care needs assessment has been carried out either by the home or health care or social care agencies. EVIDENCE: The Statement of Purpose and Service User Guide providing information about the home and the services offered have recently been updated to reflect recent changes in management. The registered manager said that these documents are given to prospective residents and their relatives/representatives during their initial visit to the home. One relative said she thought she had a copy of this but was not certain and it is recommended that an admission check list is used to identify when documents have been given and to whom. There is a detailed admission procedure, and this is included in the statement of purpose identifying the needs of residents coming into the home. Care records of residents admitted since the National Minimum Standards were written all showed that a pre-admission assessment had been carried out and Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 9 this had formed the basis of their care plan. Two residents said that their family had made the arrangements for coming into the home and records examined showed this. Both members of care staff spoken to knew about the care needs of residents and were aware of the homes pre-admission assessment procedure. Although neither had been involved in this process, they said that senior staff always discuss the needs of new residents prior to admission. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 The care planning system in this home provides detailed information and contributes to making sure that the health and care needs of residents and their preferred lifestyles are met. Individual risk assessments are written and these identify who is at risk and the action needed to minimise the risk, however, these must show that they are regularly reviewed. EVIDENCE: Each resident has an individual plan of care. Those examined contained sufficient information to ensure that all aspects of health, personal and social care needs are identified and planned for. They were up to date and showed that residents and/or their representatives have been involved. However, risk assessments did not show that they are regularly reviewed. A risk assessment should be written regarding one resident who has dementia care needs and tries to leave the building. Two residents spoken to were able to describe their care needs and these were clearly identified in their individual plan of care. Both staff spoken to work as key-worker for residents and had a clear understanding of their responsibilities. Observation of residents being given their medication was undertaken and this was done appropriately and in accordance with the home’s procedures. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 Social activities are arranged after discussions with residents. Relatives and friends of residents are made welcome in this home. EVIDENCE: The home provides a range of activities and residents have recently been to see the ‘Scarecrows’ at Faldingworth. The manager said that the home’s activity co-ordinator has recently resigned and plans are in place to advertise this role. One resident spoken to said that she liked to draw and join in with quizzes and bingo. Residents said that their friends and relatives are always made to feel welcome and are always offered a drink on arrival. One relative spoken to said that she visits 3 or 4 times a week and confirmed that she is always made to feel welcome. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 takes the issue of addressing complaints very seriously and residents are confident that their concerns will be listened to and acted upon. There is a complaints procedure for residents and/or their relatives to follow. EVIDENCE: The home has a detailed complaints procedure and this is given to all prospective residents and their relatives/representatives. However, one relative said that she could not remember being given this information and it is recommended that this is re-issued. One resident said that she felt able to raise any issues of concern herself whilst others said they would speak to their families. Staff spoken to knew the complaints procedure well and said that they felt confident to make a complaint if necessary. No complaints have been received by the Commission since the last inspection. However, one adult protection issue is currently being investigated by Social Services. One member of staff spoken to said she had undertaken adult abuse training using video tapes and questions, the other member of staff said that she was called out of the training and plans to complete the next session. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 & 26 Residents living in this home live in a safe and comfortable environment. The standard of the environment is good with the home continuously improving the decor on a planned basis. However, the health and safety of residents and staff could be improved by the addition of an enclosed sluice. EVIDENCE: The home is clean and well decorated. All furnishings are of a domestic nature and residents said they like the home, and are happy with their bedrooms and felt that they were kept clean. One bedroom was viewed, this was individually decorated and furnished and contained personal items reflecting individual interests and taste. There is an on-going programme of redecoration and refurbishment. Maintenance records identify the work that has been undertaken and projected work for the coming year. However, the property department at head office have now taken responsibility for contracting engineers to carry out maintenance of equipment and service documents/certificates are being sent to head office and are unavailable in the home. Building risk assessments are written and regularly reviewed and updated. Bathrooms and toilets were clean and are lockable. There are hoists available Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 14 and handrails to assist residents and the use of one hoist was demonstrated to the inspector. The home does not have the facility of an enclosed sluice and this was recommended during the previous inspection, however, to date this has not been addressed. Staff said they felt they worked in a safe environment, however one said that she had not received specific training in health and safety but this had been incorporated in her induction training and a specific course has been booked for October. Residents also said they felt safe living here. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 The staff group are an established team and staffing levels throughout the day are sufficient to meet the current needs of residents. However, there are only two staff on duty at night and this must be reviewed to ensure that sufficient staff are available to meet the needs of residents throughout the night. EVIDENCE: Residents spoken to did not express any worries about the level or availability of staff and during the inspection staff were seen to promptly attend to residents needs. Two residents spoken to said “all staff are very nice” and “the staff are very kind and helpful”. One resident said that she had used the emergency bell at night to request help and had been told she would have to wait until staff had time to attend to her, however, another resident said that staff always respond quickly. Records showed that there are always four care staff on duty each morning and three care staff each afternoon. In addition to this there is always a team leader on duty. Staff said that if no one is ‘off sick’ four staff is sufficient to meet the needs of residents currently living in the home. The manager explained that since the last inspection her budget for staff has increased and an additional member of care staff now works from 4pm until 10pm. Plans are in place for September for one member of staff to start work at 7am. However, there are only two staff on duty at night and a recommendation was made at the last inspection for a review of residents needs to be undertaken to ensure that enough staff are on duty during the night. To date this has not been addressed. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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) 33 There is clear leadership within this home. It is led by a trained and committed manager with the support of the organisation of The Orders of St John Trust. EVIDENCE: Residents and staff gave positive comments about the management of this home and said that they feel they can approach them at anytime if they have any concerns. Records are available to show that staff receive regular one to one time with their supervisors and staff spoken to confirmed this. There are regular resident and staff meetings and records were available, however relative meetings are not held and during a discussion with one relative said she would be interested in attending a meeting once or twice a year. This was brought to the attention of the manager who said she would look into this. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 17 Quality assurance questionnaires are currently being given to residents and staff are working through ‘Evaluating the Quality of Care’ manual which is a self assessment document produced by the Trust. Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x x Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 19 yes 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 27 Regulation 18[1][a] Requirement It is a requirement that a staffing review is undertaken in relation to the needs of service users at night and that staff are available in appropriate mumbers to administer to service users needs.(Timescale of 30.04.05 not met) Timescale for action 31.10.05 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 1 Good Practice Recommendations It is recommended that an admission check list is used to identify when documents are given to residents and their relatives/representatives. It is also recommended that the revised statement of purpose and service user guide is reissued to residents. It is recommended that risk assessments evidence that they are regularly reviewed. A risk assessment should be written for one resident who tends to leave the building. It is recommended that copies of maintenance and service documents/certificates are available in the home. It is recommended that meetings are set up for relatives and representatives of residents. C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 Page 20 2. 3. 4. 7 19 33 Hartsholme House Commission for Social Care Inspection Unity House The Point Weaver Road off Whisby Road Lincoln LN6 3QN 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 Hartsholme House C53 C04 S2369 Hartsholme House V240125 010805 Stage 4.doc Version 1.40 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!