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Inspection on 13/12/05 for Hartwell Residential Home

Also see our care home review for Hartwell Residential Home for more information

This inspection was carried out on 13th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Residents themselves said that they were happy at the home and the staff were lovely. Residents were well dressed in clean clothes and had received a good standard of personal care. Residents said they chose when they got up and went to bed and had a choice of food at mealtimes. The home was generally clean, with no unpleasant odours noticeable. Residents said that they met regularly with the manager and spoke positively about her approachability and helpfulness.

What has improved since the last inspection?

The linoleum in a bathroom had been replaced. There had been an improvement in recruitment practices since the last inspection. There had been an improvement in the recording systems of the fire drill records. Staff were receiving fire safety training on a more frequent basis.

What the care home could do better:

The daily entries made in the care plans by staff need to be more specific to the actual care plan. Fire drills need to happen at different times of the day and night. The toilets and bathrooms need redecorating and refurbishing. The cleanliness of the toilets needs to be improved.

CARE HOMES FOR OLDER PEOPLE Hartwell Residential Home 117 Jumble Lane Ecclesfield Sheffield South Yorkshire S35 9XJ Lead Inspector Michael O’Neil Unannounced Inspection 13th December 2005 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 Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hartwell Residential Home Address 117 Jumble Lane Ecclesfield Sheffield South Yorkshire S35 9XJ 0114 2468422 0114 2466417 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) None Southern Cross Care Homes No 2 Limited Mrs Kathleen Mary Webb Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels must meet the Residential Staffing Forum levels required for older people. 13th June 2005 Date of last inspection Brief Description of the Service: Hartwell is a residential care home for older people; it is registered to provide personal care and accommodation for 32 service users. Hartwell is situated in the North of Sheffield in the district of Ecclesfield.The home is set in large grounds, off a country road and transport is needed to reach the home. Amenities such as shops, libraries, church and local services are based in the near by communities of Chapeltown and Ecclesfield. The home comprises of two levels with lift access to the upper level. The home was accessible for wheelchair users. There were a suitable number of lounges and dining rooms and the homes gardens are extensive with views across the countryside and the home had a car park. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mike O’Neil carried out this unannounced inspection from 9:20 to 12:55. Kath Webb ,registered manager, was present for the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of records and policies and talk to 3 staff, a visiting relative and 12 residents. The inspector wishes to thank the staff and residents for their time, friendliness and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The daily entries made in the care plans by staff need to be more specific to the actual care plan. Fire drills need to happen at different times of the day and night. The toilets and bathrooms need redecorating and refurbishing. The cleanliness of the toilets needs to be improved. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 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. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Residents’ needs had been assessed. EVIDENCE: Two resident files were checked and each contained a copy of their full needs assessments. The information from the full needs assessment had been incorporated into the resident care plans. This will enable staff to plan and meet the residents’ needs. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8 and 10. Care plans contained information relating to the residents health, personal and social needs. Residents themselves said that they were happy at the home and the staff were lovely. Residents’ privacy and dignity was maintained. EVIDENCE: Two resident plans of care were checked. Each set out individual needs and the action required by staff to ensure those needs were met. The care plans identified that a range of health professionals visited the home to assist in maintaining the residents health care needs. Residents or their relatives were involved in drawing up and evaluating the plans. However the daily entries made in the care plans by staff were not specific to the actual care plan. For example documenting that the resident had had a “fine day” is not adequate. Residents said that they were happy and that the staff were “lovely”. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 10 Residents were well dressed in clean clothes and had received a good standard of personal care. Staff were observed to be assisting residents in a positive and friendly manner, doors were closed where staff were helping with personal care. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends. Meals served at the home were of a good quality and offered choice. EVIDENCE: Residents said that they were able to maintain contact with their family and friends and said that their relatives were always made to feel welcome when they visited. A friendly and very welcoming feel was evident in Hartwell. Residents said they chose when they got up and went to bed and had a choice of food at mealtimes. Residents said that activities were available both within the home and on trips outside the home. Residents said that they had enjoyed a carol concert, which had been recently performed by local school children. Lunch was served in a pleasant relaxed manner and the residents said that they enjoyed their lunch. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 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): None of these standards were checked as the key standards were checked and met at the last inspection. EVIDENCE: Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 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): Standards 19,20,21,24,25 and 26. The environment within the home was generally well maintained and clean providing a comfortable, safe environment for residents. EVIDENCE: Lounge and dining areas were domestically furnished. Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. The home was generally clean, with no unpleasant odours noticeable. Residents said that the home was always kept clean. The bathrooms and toilets looked tired and looked clinical and stark. The rooms need redecorating and refurbishing. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 14 The toilet seat in one room was not clean and the room contained no toilet paper, soap or paper towels which would increase the risk of cross infection. The home was warm in all areas. Window restrictors were fitted to all windows checked. This will assist in maintaining resident safety. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28 and 29. Staff were employed in sufficient numbers. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. EVIDENCE: The manager stated that agreed staffing levels were being maintained. The staff rota identified agreed staffing levels had been met. This will assist in making sure that residents’ needs are met. Staff said staffing levels were adequate. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. A staff file checked contained references from the staffs last employer, information to verify identity and a Criminal Record Bureau (CRB) check. Fifty per cent of care staff had not achieved their level 2/3 NVQ qualification. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,35 and 38. There was a positive style of management in the home. In the main the homes policies and procedures promoted the health, safety and welfare of residents and staff. EVIDENCE: Residents said that they met regularly with the manager and spoke positively about her approachability and helpfulness. The resident personal money accounts were examined by the inspector and were found to be up to date. The inspector saw a receipting system and statement sheets for each resident. A sample of records showed that staff were receiving fire safety training and other statutory training. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 17 The safety of the residents and staff could not be fully maintained because fire drill records did not indicate that the drills were being held at different times of the day so that all staff could participate in a drill. At the time of inspection fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of the service users. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 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 X 17 X 18 X 2 3 2 X X 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X X 2 Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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. 2. 3. Standard OP7 OP21 OP26 Regulation 15 23 13 Requirement Timescale for action 01/03/06 4. OP38 23 Daily entries made in care plans by the staff must be specific and relate to the actual care plan. All areas of the home used by 01/05/06 residents (toilets and bathrooms) must be well maintained. To minimise the risk of spreading 01/01/06 infection toilets must be kept clean and toilet paper, soap and towels must be provided in the rooms. Fire Drills must be conducted at 01/03/06 different times of the day/night so as to ensure that all staff working at the home are aware of the procedures to follow in the event of fire. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 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 OP28 Good Practice Recommendations Efforts should continue to ensure that 50 of staff are trained to NVQ level 2 or equivalent by 2005. Hartwell Residential Home DS0000032211.V268785.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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