Inspection on 24/02/06 for Hartsholme House

This inspection was carried out on 24th February 2006.

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

Hartsholme House 13/11/06

Hartsholme House 02/08/05

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 Lincs LN6 0ED Lead Inspector Dawn Podmore Unannounced Inspection 24th February 2006 10:15 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 Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hartsholme House Address Ashby Avenue Hartsholme Lincoln Lincs LN6 0ED 01522 683583 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) The Orders Of St John Care Trust Mrs Jacqueline Luke Care Home 42 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (35) of places Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 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 but 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 DS0000002369.V284562.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 4 hours. The main method of inspection used was called case tracking which 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. A partial tour of the premises was conducted staff and maintenance records were examined. The inspection also included a general discussion with the manager, the cook and residents living at the home. What the service does well: What has improved since the last inspection? What they could do better: Three recommendations were made following this visit. Although the cook has a good knowledge of resident’s special requirements and preferences the home needs to make sure that forms held in the kitchen are comprehensive and up to date. The manager needs to continue to monitor the staffing levels to ensure that there is enough staff on each shift to meet the current needs of people living at the home. The records of who has made withdrawals and deposits from residents personal accounts could be more comprehensive and it was also recommended that two people sign for each entry, as this would provide extra security. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 6 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 DS0000002369.V284562.R01.S.doc Version 5.1 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 Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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): 1 The home provides good information to people in relation to the home and how it operates. EVIDENCE: Although these standards were not fully inspected as part of this inspection the recommendations from the last visit had been addressed These were in relation to the introduction of an admission checklist, to be used to identify when documents had been given to residents, and ensuring that all residents have an updated copy of the Service User Guide. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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): 10 Staff show appropriate respect to residents while maintaining their privacy and dignity. EVIDENCE: Observation and comments from residents and staff demonstrated that staff respected people’s privacy and dignity. They were seen knocking on people’s doors and speaking to them in a friendly, respectful manner. Comments included: ‘the staff are very good, you can’t fault them’, ‘it’s important to make sure that you close doors and cover people when bathing them’ and ‘they always knock on the door and they ask if you are happy with the way they are doing something’. The recommendation made at the last inspection regarding the completion and regular evaluation of risk assessments had been implemented. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 10 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, 14 & 15 Staff encourage people living at the home to make choices about their day-today lives. Meals provided offer variety and choice. EVIDENCE: Residents said that the staff offered them choices such as, what they preferred to eat, the time they preferred to get up and whether or not they wished to join in activities and social events. Staff outlined how they supported people to make decisions within their capabilities so that they could remain as independent as possible. Details of people’s preferences are recorded in their care plans so that staff are aware of them. Residents and staff discussed how people joined in the recently extended activity programme at the home. Four residents were eating their lunch in the recently converted activities centre ‘Treetops’ this includes a sitting room and a dining area with a kitchenette. They all said that they could choose if they ate there or in the main dining area. Resident’s artwork was displayed on the wall and people said that they had also taken part in movement to music, balance therapy and reminiscence therapy. Lunch on the day of the visit was nutritionally balanced and well presented. The main menu consisted of soup, fish, chips and mushy peas or chicken breast, followed by milk pudding, fresh fruit, cheese and biscuits or yoghurt. The home also provides alternatives for people needing special diets, such as Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 11 diabetics, vegetarians, and residents needing a soft diet. Residents said that they enjoyed the food provided, comments included ‘you get a very good choice and the quality is good’, ‘I have no complaints, I am very happy’ and ‘the food is really good, I have been here 7 years and I wouldn’t want to go back home’. Residents said that they had been offered a choice of menu the day before and their preferences had been recorded. Some people were seen using specially adapted cutlery to enable them to remain as independent as possible. The cook had a good knowledge of people’s dietary requirements and preferences. Both she and the assistant cook have attained the intermediate food hygiene course, which means that they are qualified to teach the care staff about food hygiene. Although the kitchen staff demonstrated a good knowledge of peoples needs and preferences it was recommended that information held in the kitchen should be comprehensively completed, and updated as necessary, to ensure that staff were aware of any changes. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected as part of this visit. EVIDENCE: Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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 the following standard(s): 19 & 26 Residents live in a safe and comfortable environment. The standard of the accommodation is good with the home continuously improving the decor on a planned basis. EVIDENCE: A partial tour of the building showed that the home was well maintained with well-kept lawns and gardens. Bedrooms had been personalised by the residents or their families with photographs, mementoes and small items of furniture. Residents said that they were happy with their rooms and the generally facilities provided in the home. The manager described plans to redecorate the staircase, front entrance and both downstairs corridors in the near future. This will include some new carpets. On the day of the inspection the home was clean, tidy and odour free throughout. The manager confirmed that she attended an in depth risk assessment course in January and this will enable her to update all risk assessments pertaining to the building. At the last inspection it was recommended that original servicing certificates be kept at the home, these were available. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 14 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, 28, 29 & 30 Minimum staffing levels are being met. The procedures for the recruitment of staff are robust and therefore offer protection for people living at the home. Staff who are well trained and supported cares for people. EVIDENCE: The requirement made at the last inspection regarding reviewing residents needs to ensure that enough staff were on duty during the night had been addressed. The manger has analysed the dependency levels and concluded that the current staffing levels are appropriate. It was recommended that these be continually monitored and staffing levels adjusted accordingly. Staff who work days and nights confirmed that the levels were satisfactory, and one stated that there would not be enough to do if 3 staff were on duty at night. Residents said that their needs were being met and none raised any concerns regarding the availability of staff at any time of the day or night. Comments included: ‘the staff are wonderful’, they are so good to me’ and ‘the girls are so helpful, I can’t fault them’. The home has a recruitment procedure, which included obtaining written references and C.R.B. (Criminal Record Bureau) checks to make sure that potential staff are suitable to care for the people living at the home. The files for two members of staff contained all the necessary documentation to show that the procedure had been followed. One recently recruited member of staff confirmed that she had been recruited in line with this procedure. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 15 The home has a good training programme, which includes mandatory and specialist training to make sure that staff have the necessary knowledge and skills to meet the need of the residents. This includes an induction programme, which tells new staff how the home operates and how care is to be delivered. A newly recruited carer said that her induction had included a week shadowing a senior member of staff until she was assessed as competent. Records and staff comments confirmed that training provided included; adult protection, manual handling, fire safety, health and safety, basic food hygiene, first aid, loss and bereavement, dementia, infection control and administration of medications. Four care Leaders and 12 care staff have attained an N.V.Q. (National Vocational Qualification) in care. Seven others are currently undertaking the course; this along with the other training provided should enhance the quality of care at the home. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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): 31, 35 & 38 There is sufficient leadership, guidance and direction to staff to ensure residents receive a good standard of care. The procedure for handling residents’ monies is satisfactory but would benefit from minor amendments. Maintenance and working practices in the home promote the health and safety of residents. EVIDENCE: A Registered Manager who has the appropriate qualifications and experience manages the home. Residents and staff made positive comments about the home and how it was managed. These included: ‘the manager is very approachable’, ‘the manager is very nice, I have never worked in such a good team’ and ‘ the management of the home is good and we receive regular support from the manager and care leaders’. A recommendation made at the last inspection regarding residents meetings being held had been addressed. Residents receive 4 weeks notice of a meeting taking place and the minutes are recorded. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 17 Accounts for resident’s personal monies were sampled and found to be satisfactory. These could be improved by ensuring that all entries include two signatures when transactions are made, where possible one of which should be the resident or their representative. When deposits and withdrawals are made the record should clearly state who has made these as this will provide a more accurate audit trail. Both internal and external audits take place regularly. Pre inspection information completed by the manager demonstrated that the routine maintenance of equipment such as fire extinguishers, hoists, lifts and gas equipment had been carried out as required. This information was verified by documentation sampled on the day of the visit. In February the home successfully attained the ISO9001, which is awarded by is an independent company who audit the home’s systems against expected standards. They have also maintained the Investors In People award, which was first awarded in 1998. These awards demonstrate that the home is committed to maintaining and improving the quality of the service it provides. Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 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 Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 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. 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 Refer to Standard OP15 Good Practice Recommendations It was recommended that information held in the kitchen should be comprehensively completed, and updated as necessary, to ensure that staff were aware of any changes. The manager should continually monitor staffing levels in conjunction with resident’s dependency levels to ensure that sufficient staff are available to meet peoples needs. Resident’s financial transitions for deposits and withdrawals should be recorded in more detail. They should also be checked and signed for by 2 people to offer added security. 2 3 OP27 OP35 Hartsholme House DS0000002369.V284562.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Lincoln Area Office 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 DS0000002369.V284562.R01.S.doc Version 5.1 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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