Inspection on 18/06/07 for Hatch Mill

This inspection was carried out on 18th June 2007.

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 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

Hatch Mill 30/01/06

Hatch Mill 07/06/05

Hatch Mill 23/09/04

Hatch Mill 26/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hatch Mill Hatch Mill Mike Hawthorn Drive Farnham Surrey GU9 8AS Lead Inspector Sue McBriarty Unannounced Inspection 18th June 2007 10:00 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 Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatch Mill Address Hatch Mill Mike Hawthorn Drive Farnham Surrey GU9 8AS 01252 899000 01252 899042 hatchmill@ukonline.co.uk 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) Abbeyfield Wey Valley Society Limited Tracey Jane Scurr Care Home 36 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (36), Physical disability (1), Physical disability over 65 years of age (2) Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Hatch mill is owned and managed by the Abbeyfield Way Valley Society Ltd. The service is registered to provide personal and nursing care for up to 36 older people over the age of 65 years including 5 with Dementia. The home is set over two floors and stairs or lift allows access to the first floor. The home is accessible to people who use a wheelchair. The thirty six bedrooms all have en-suite toilets. Bathrooms are shared and have been fitted with specialist bathing equipment as necessary. A number of communal and dining areas are provided to allow for small groups of people to be together or to allow for private meetings with relatives and friends. The building was completed in 2001 and incorporates the remains of the old mill that had been built on the river Way and is easily accessible close to the town centre of Farnham and major road links to the motorway and adjoining towns. The town centre offers many high street shops, café, restaurants, churches and theatres. There is ample car parking space available. Fee levels at the time of the visit were as follows: Residential care minimum fee £530 up to £570 per week. Nursing care £705 to £745 per week Respite care nursing £740 per week inclusive of hairdressing, chiropody and newspapers. Respite residential £600 per week inclusive of hair, chiropody and newspapers Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven (7) hours, commencing at 10:00am and ending at 5:00pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The manager was available throughout the inspection. The inspection took into account the Annual Quality Assurance Audit (AQAA) completed by the home as required by the commission. Other information looked at by the commission included residents files, staff personnel files, training information, medication administration records and care records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents and staff. Twenty three comment cards or surveys completed by the residents, relatives and health professionals were received by the commission. What the service does well: What has improved since the last inspection? The requirements from the inspection of the 30th January 2006 had been met. The heating is checked on a regular basis to make sure it is working consistently. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 6 A new system for care planning was in place that made clear the assessed needs of the resident and how their needs were to be met. The content of the records and documents seen by the commission had improved. The home had asked a dietician to visit the home to help them make sure they were providing the range of food needed to make sure residents nutritional needs continued to be met. What they could do better: A number of requirements and recommendations were made following the key inspection. The statement of purpose and service user guide needs review to make sure all the information needed about the home is provided; for example the experience and qualifications of the staff team. Some work is needed to make sure that all the information necessary had been consistently recorded on all documents including the pre-admission assessment, the file front sheet and the care plans. Written confirmation is required to make sure that risk assessments had been completed setting out clearly why lap belts or similar restraints were in use to verify that this was in the best interests of the people who use the service. The policy and procedure for the use of restraint needs review to make sure that the practice of the home was supported by policy and ensures that residents’ best interests were safeguarded. A recommendation is made that the activities provided by the home be reviewed to make sure they are accessible by any one who chooses to join for example residents with a visual impairment or who have dementia. The policy for dealing with complaints needs some work to confirm the practice of the home to accept a complaint either verbally or in writing. This will confirm that any resident who for any reason is unable to write their complaint can be confident that a verbal complaint will be taken seriously. The policies and procedures for safeguarding adults and whistle blowing need improvement to make sure that the practice of the home was supported by policy and confirm that the local authority guidelines were being followed. Confirmation in writing is needed to make sure that the home would purchase and provide the furniture necessary for any resident who did not have their own furniture or chose not to bring their own furniture to the home. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 7 In order to make sure that the information needed to confirm safe recruitment practice is in place the home is required to investigate the date of receipt of the protection of vulnerable adults checks (PoVA) and date of employment of all members of staff and record the outcome in the personnel files. The home had carried out a number of quality assurance checks with staff and residents and a requirement is made that the information be collated, published and made available to residents, relatives and other stakeholders. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were assessed. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have the information they need about the home to help them make a decision about moving in. Some work was needed to make sure that documents such as the statement of purpose and service user guide have all the information needed. EVIDENCE: The commission received twenty three (23) completed surveys from relatives and people who use the service. However those completed by relatives and residents included care managers and health professional surveys where the questions asked varied slightly and this has affected the reported outcomes. Twelve of the questionnaires asked if enough information was received about the home before moving in, nine (9) said all the information needed was provided, two (2) usually and one (1) did not respond. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 10 One said it would be helpful if relatives were involved in the assessment so they could have their views taken into account. Another said we were encouraged to visit as many times as we wished. The commission looked at the statement of purpose and service user guide and found that some of the information included details of other homes owned by the organisation. In addition the detail needed about the home had not all been included for example the qualifications and experience of the members of staff working at the home. Please also see the section on concerns and complaints. A requirement is made for the statement of purpose and service user guide to be reviewed and revised to make sure the documents are individual to the home and have all the information necessary about Hatch Mill. A number of files were sampled and assessments had been completed before the residents had moved into the home. Feedback from people who use the service and their relatives said that they had been able to visit the home and ask questions before making a decision to move in. Please also see the Health and Personal Care section of this report. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed and changing needs regarding the health, personal and social care needs of the people who use the service are documented and recorded some work was needed to make sure that all the information recorded matched. Confirmation was needed about specific risk assessments to confirm safe and appropriate action was being taken by the home and that policy met practice. The policy and practice of the home regarding giving medication supports and protects the residents. EVIDENCE: A number of care plans were sampled and the information provided by the home in the Annual Quality Assessment Audit (AQAA) confirmed. The manager said that the care plan system had been revised and most had been changed to the new system, about four still needed change. The care plans set out the assessed needs of the people using the service and how they were to be met Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 12 and also noted individual likes and dislikes and how a resident might respond if unhappy. One care plan identified that the resident had diabetes and the care plan stated that some dietary restrictions were in place. The information was not confirmed on the front information page, which said that the diet was ‘normal’. Evidence in the care plans showed that they had been reviewed and a separate record was being made and signed by the resident to confirm agreement to the care plan. Feedback from people who use the service confirmed that care plans were reviewed with them. The manager said she had also recently introduced a document to record what was discussed during the reviews with the people who use the service and or their relatives. A number of these were sampled and a record of the discussions had been made with comment about the action needed. One sampled talked about a therapy being provided to a resident but did not make clear whether the therapy was to continue following some difficulty in introduction. A requirement is made to ensure that all the assessments, care plans and review documents are reviewed and where necessary revised to make sure the records are clear and say the same throughout. The requirements from the inspection of the 30th January 2006 had been met. Risk assessments had been completed however one matter was discussed in detail with the manager. The manager had contacted the local doctor and a response had been received from the Director of Public Health that did not support a referral to an Occupational Therapist. Following this visit the manager made further contact with the doctor and with the local authority safeguarding team. The manager told the commission that they had recorded all the information received to confirm that the seating in use was in the best interests of the resident. The manager told the commission that with the advice from the safeguarding team they are in the process of making a referral to the local authority team for an assessment from an Occupational Therapist. A requirement is made that the home confirms the action taken to date in writing to the commission. The manager told the commission that lap belts were being used to assist some residents to stay safely in the wheelchair when going out. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 13 Risk assessments had not been completed for the use of restraints. On the 21st June 2007 the manager contacted the commission to confirm that risk assessments had been completed and that residents would be asked to sign where possible their agreement for the use of a lap belt. A requirement is made for the home to confirm in writing that risk assessments had been completed. The home had a policy regarding restraint. A requirement is made for the policy to be reviewed and revised taking into account the practice of the home and the assessed needs of the people living at the home and support safe, recorded and documented decision making about the use of lap belts. Visits by health professionals and the outcome had been recorded, signed and dated by the person completing the document confirming that the health care needs of the people living at the home were being met. Feedback received from sixteen (16) of the twenty three (23) residents said that health care needs were always met and seven (7) said they were usually met. Three (3) surveys received from doctors who attend the home said that the home communicated clearly with them and acted appropriately to the health needs of the residents and that medication was also appropriately dealt with. The home has a policy and procedure for giving medication and one member of staff spoken with confirmed that only nurse qualified or senior care staff gives medication. The same member of staff said that training for giving medication had taken place last week. The medication records for the home were found on top of the medication trolley in the hallway of the home. This matter was brought to the attention of the manager and the records were removed immediately to ensure confidentiality. Observations were made of a member of staff giving medication during lunch. The medication was left on the table with the resident and marked as having been administered. The commission discussed this with the member of staff who said that medication was given like that to only a few residents. A risk assessment had been completed and signed by the resident confirming the information given by the member of staff. The commission saw the completed risk assessments. The manager said that this made sure that residents could remain as independent as possible and retain some control over their medication. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 14 One person told the commission that the home continually assess care and medication needs and adapt to on-going needs another said they do an excellent job so just need to keep doing the same. Feedback from residents and their relatives said that people were treated with respect and dignity. On issue raised was discussed with the manager who advised that these matters had been dealt with. Observations made by the commission during the inspection confirmed that members of staff treated residents with respect and were called by their given name. Please see the concerns and complaints section of the report. . Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social, leisure and recreational needs of the people who use the service are met in the way they require and prefer allowing people to have choice and control over their lives. Some work would further confirm that the activities provided are accessible to all. Meals are varied appealing and information about residents nutritional needs are assessed and met by the home. EVIDENCE: Feedback from seven (7) people who use the service and their relatives said that activities were always provided (2) usually provided and (5) sometimes. Some said they had difficulty attending the activities provided due to their visual impairment or dementia. The manager said that some items had been ordered to take account of visual impairments for example large playing cards. A sensory room was also available for those who might benefit from an area to relax in. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 16 Feedback received by the commission and discussion with people who use the service confirmed that family and friends are welcome into the home and their views are listened to. Questionnaires sent out by the home and the information provided in the AQAA confirmed that an activities co-ordinator was in post. Those residents spoken with during the visit spoke highly of the co-ordinator but did note that when she was away for any reason a number of activities did not take place. A residents meeting is held regularly at the home and minutes are taken. A number of the minutes were sampled and showed that the meeting gave the residents an opportunity to talk about anything happening within the home. The issues discussed included meals, a visit about a mission abroad and preferred activities including who should visit the home and why. The religious and spiritual beliefs of people who use the service are recorded and a Christian service is provided within the home on a regular basis for those who wish to attend. The AQAA stated that the home would assist those who had other beliefs to attend a place of worship of their choice. A recommendation is made that the activities within the home are reviewed to make sure that the range of activities provided take into account the assessed needs of all the people who use the service. This will assist the home to make sure the activities are available to all and that non-attendance is a matter of choice not inability to access for any reason. The manager said that a dietician had attended the home and reviewed the menu provided; we looked at the dieticians report during the visit. Some recommendations were made including the use of a system that helps members of staff to identify people at risk from malnutrition. The system has begun at the home although the manager said it was not yet in full use. Questionnaires sent out by the home asked about the food provided, the comments made in those questionnaires confirmed some of the information received by the commission about the food provided. Several people made comment that the meat was on occasion tough and difficult to eat; one said the food sometimes lacks imagination. The manager told the commission that the meat was from a local butcher and that she was trying to resolve the problem and was meeting with the cook on a regular basis and talking to residents about the problem. This was confirmed in the minutes of the residents meetings viewed by the commission. The commission observed the Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 17 serving of lunch during the visit, two hot choices were available and lunch was seen to be an opportunity for people to chat and relax. The AQAA stated that all the kitchen staff and 60 of the care staff had completed food hygiene training. The commission observed members of the care staff assisting with serving lunch. Records seen confirmed that food hygiene training had been completed. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service and their relatives can be confident that their views are listened to and acted upon some work is needed to confirm that all complaints no matter how received will be dealt with. The policy of the home about safeguarding adults needs improvement to make sure that it supports practice and the local authority guidelines. EVIDENCE: The home had a complaint policy, the policy set out the timescale for a response to a written complaint but not verbal complaints. Some of the people living at the home may not be able to hand write or use a keyboard due to a physical or visual impairment in order to make a written complaint. It is required that the complaint policy be reviewed taking into account the assessed needs of the people living at the home and to support the practice of the home to accept verbal complaints. Feedback about complaints was received from seventeen people who use the service and their relatives; twelve (12) said that staff always listen and act on what they say and five (5) said staff usually listen and act. One said that things can take time to change and another said that it depended on the member of staff spoken with. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 19 The manager told the commission said that since the inspection of the 30th January 2006 two (2) complaints had been received and dealt with by the home and the complainants satisfied with the response. The AQAA stated that three (3) complaints had been received two (2) of which had been upheld on investigation by the home all had been resolved within twenty eight (28) days of receipt. The manager told the commission that two (2) safeguarding (adult protection) referrals had been made by the home since the inspection of the 30th January 2006 these matters had been dealt with appropriately by the home in line with the local authority guidelines. The commission looked at the home’s policy and procedure for safeguarding adults and whistle blowing. A requirement is made for the both policies and procedures to be reviewed and revised to make sure they support the local authority multi-agency procedures and the practice of the home and ensure that all members of staff are clear about what to do if a referral is made. The AQAA provided by the home and in discussion with the commission the manager confirmed that any allegation would be referred to the local authority. The manager and one member of staff spoken with said that nurse qualified and senior care staff had recently received training about protecting adults. Concerns raised in feedback received by the commission were discussed with the manager the details of the issues raised had been dealt with by the home previously either through the safeguarding referrals made or complaints received. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is safe, well maintained and comfortable and is kept clean and hygienic making sure the people who use the service are safe. EVIDENCE: The commission toured the home and saw some of the bedrooms and all of the communal areas. The AQAA provided by the home said that people moving into the home were encouraged to bring their own furniture. The manager confirmed this during the visit and said that if the prospective resident did not have any furniture the home would seek to provide. It was unclear who would replace furniture of current residents if this were required. A requirement is made that the home confirms that bedroom furniture can be and is purchased and provided by the home as necessary. All the bedrooms had a built in wardrobe and en-suite toilet facilities, bathroom facilities are shared. Those Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 21 bedrooms seen had been personalised by the residents including photographs, pictures and furniture. Access to the first floor was by stairs or lift and entry codes were present on each of the areas upstairs to assist with safety matters. The AQAA received from the home confirmed that a nurse call system was in place and the manager monitored call times. An infection control policy was in place and was part of the induction programme for new members of staff. The home was fresh, clean and hygienic throughout, feedback was received from seven (7) people who use the service about the home; four (4) said the home was always clean and three (3) said it was usually clean. One person said the appearance of the home was always good. The door and window frames of the home were of solid wood and the organisation had taken the decision to allow the external wood to age and colour naturally. The AQAA received by the commission confirmed that a heating engineer checked the heating at the home on a regular basis. The requirement from the inspection of the 30th January 2006 that the heating works consistently was met. No issues were raised through feedback from residents or relatives about the maintenance of the home and no issues were brought to the attention of the manager by the commission. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policy and practice of the home regarding recruitment, training including qualifying training supports and protects the people who use the service. Some further work was needed to further confirm good recruitment practices. EVIDENCE: The AQAA received by the commission stated that a nurse qualified member of staff is on duty 24 hours a day. Four care assistants making a total of five staff to sixteen residents supported the nurse-qualified person in the nursing section of the home. A floating support worker may also be available and their duty was said to include caring for people using the respite care service. In the residential service a senior care assistant is available each morning and afternoon shift working with two care staff. This meant that there was three staff for sixteen residents. A domestic was provided for each wing of the home and a kitchen assistant was also available to work with the cook or assistant cook. The AQAA gave the ethnicity of thirty nine staff employed by the home twenty four (24) were white British, two (2) from another white background, one (1) Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 23 was Indian and twelve (12) were black African and one declined to give ethnicity. The same document said that forty seven (47) staff was female and one was male. Thirty two (32) people were using the service at the time of the visit thirty one (31) were female and one (1) male. Twenty four (24) people who were using the service were white British; one (1) from another white background and six (6) did not wish to say. The homes had an equal opportunity policy the manager confirmed that training in equal opportunities or diversity had not been provided to the staff team. A recommendation is made that training in equal opportunities and or equality and diversity are provided to the members of staff to support increased awareness and understanding of difference including ethnicity, age and gender. The AQAA also set out the qualifying training completed. Twenty seven (27) care staff work at the home of whom twelve (12) were qualified to National Vocational (NVQ) Level 2 or above and three were working on their NVQ. Eight bank staff was employed by the home one of whom had completed their NVQ. The manager said they were in the process of introducing the common induction standards as part of their induction programme. Induction at the home included observed practice taking place and a senior member of staff placing in writing the outcome of the observations made. A number of personnel files were sampled during this visit. The manager said that the policy of the organisation was to hold all the recruitment documents at the home. All the files sampled held references, the completed application and a separate document setting out the full employment history of the person applying. Not all the files sampled held confirmation of identity although Criminal Record Bureau (CRB) checks had been received for all those sampled which would have required an identity check. Only one of the most recent files viewed by the commission evidenced that a PoVA first check had been received before the member of staff started work. The PoVA first ensures a check is made against a list of people not suitable to work with vulnerable adults. The manager told the commission that where a member of staff is needed to start work before their CRB is returned a PoVA check had been requested and received. A requirement is made for the home to investigate the date of receipt of CRB’s and PoVA checks against the date of employment and where there is a discrepancy the reason for this be recorded in the personnel file and the outcomes to be made known to the commission. This will make sure that no one working at the home had started work before a Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 24 satisfactory PoVA check had been received after July 2004 when the PoVA list was introduced. In discussion with manager, the information provided by the AQAA, records and documents seen during the visit confirmed that training took place. Training included manual handling, fire safety and food hygiene. A course on manual handling took place on the day of this visit. A staff member confirmed training in pressure care, tissue viability and adult protection. The commission were informed by a member of staff that training was also provided following identification in supervision or appraisal sessions. The manager was in the process of drawing up a training and development plan for members of staff working at the home. It would benefit the home to have one document that set out the mandatory, qualifying, specific and specialist training needs of each member of staff including when completed and when due to enable easy access to information. This would assist the home to make sure that all members of staff were up to date with all the training required. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a person qualified and fit to do so who takes into account the views of the residents and their relatives and makes sure the health, safety and welfare policies and practices of the home keep residents and members of staff safe. EVIDENCE: The manager was nurse qualified and had completed the registered managers award. Information provided by the manager in the AQAA stated that she had been employed in care services for sixteen (16) years and ensured that she continued to update her training including infection control, employment law, first aid and manual handling. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 26 The questionnaires completed by people who use the service were seen by the commission as were minutes of resident meetings, action plans drawn up as part of care plan review and the feedback from residents and relatives confirmed that residents are asked about the quality of the service received at the home and that action is taken to resolve or change matters raised. The home had a lot of information about the how others see the service and a requirement is made that the home collate the information received and make the outcomes available to residents, relatives and stakeholders as part of their continuous self assessment process. The manager told the commission that the home does not assist resident with their finances and no money is kept on their behalf. Information provided in the AQAA stated that fire risk assessments had been completed, fire alarms were tested weekly and two fire drills completed each year. Policies and procedures had been reviewed in May 2007, a revised pack was sent to the home during the visit for the commission to view. Policies and procedures in place included continence promotion, fire safety, first aid and health and safety. Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 27 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 2 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 28 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. 1. Standard OP1 Regulation 4,5 Requirement The statement or purpose and service user guide must be reviewed and revised to make sure that all the information required by The National Minimum Standards for Older People and The Care Homes Regulations 2001 are available and individual to the home. This will further confirm that prospective residents have all the information they need to make an informed choice. A review of the assessments, care plans and review documents must take place to confirm that all the information in the records is the same and that review information includes the full outcome. This will further confirm that the assessed needs of residents are met. The registered person must confirm in writing to the commission the outcomes and actions taken following the discussions with other professionals regarding the specified seating issue and that risk assessments about the use DS0000013663.V338372.R01.S.doc Timescale for action 31/08/07 2. OP7 OP3 15 31/07/07 3. OP7 13(4) 31/07/07 Hatch Mill Version 5.2 Page 29 of lap belts when using wheelchairs have been completed and where possible with the agreement of residents. This will confirm safe practice. 4. OP16 22 The complaints procedure must be revised to support the practice of the home to accept verbal complaints from residents or their relatives. This will further confirm that residents and relative’s views are listened to acted upon. The policy and procedure for safeguarding adults and whistle blowing must be reviewed and revised to make sure it supports the local multi-agency guidelines on safeguarding adults and the practice of the home. This will further confirm that residents are protected from abuse. The registered person must confirm in writing to the commission that appropriate furniture can be and is purchased and provided by the home where residents are unable to provide their own or do not wish to bring their furniture. The home to investigate the date of receipt of CRB and PoVA checks against the date of employment and where there is a discrepancy to make a record of the reason for this. This will confirm safe recruitment practice. It is required that information that has been gathered by the home as part of their regular quality assurance audits are collated and the outcomes made known to residents, their relatives and other stakeholders. 31/08/07 5. OP18 13(6) 31/08/07 6. OP24 16(c) 31/07/07 7. OP29 19 31/07/07 8. OP33 24 31/08/07 Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 30 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 OP12 Good Practice Recommendations It is recommended that a review of the activities provided by the home take place to make sure that all residents have the opportunity to take part in an activity that meets their needs including those with a visual impairment or who have dementia. This will make sure that any nonattendance is by choice. It is recommended that the organisation provide training in equal opportunities and or equality and diversity. 2. OP30 Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hatch Mill DS0000013663.V338372.R01.S.doc Version 5.2 Page 32 - 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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