Inspection on 30/01/06 for Hatch Mill

This inspection was carried out on 30th January 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

Hatch Mill 18/06/07

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 Kathy Martin Unannounced Inspection 30th January 2006 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.V277610.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. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hatch Mill Address Hatch Mill Mike Hawthorn Drive Farnham Surrey GU9 8AS 01252 712021 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) hatchmill@ukonline.co.uk 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.V277610.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The age/age range of the persons to be accommodated will be: OVER 65 YEARS The gender of those accommodated will be: MALE & FEMALE Up to 20 older people may be admitted for Nursing Care Up to 5 older people accommodated may have a mental disorder and/or dementia Up to 2 older people accommodated may have a physical disability Additionally one named person in the category Physical disability aged 60 years of age may be accommodated. (As per letter dated 15th March 2004) 7th June 2005 Date of last inspection Brief Description of the Service: Hatch mill is owned and managed by the Abbey field 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 Care Home was designed to comply with the Care Standards Act 2000 and the Care Homes Regulations 2001. 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. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second CSCI inspection this year. The first inspection was undertaken in June 2005. All the key national minimum standards have now been assessed over both visits. This was an unannounced inspection meaning that the manager, staff and residents were not made aware in advance. The manager was present during this inspection and provided information that has been used in this report. The inspector spoke with several residents during the visit and to some members of staff. The comments received were very complimentary of the way the home run and how residents were cared for. During the course of the inspection the inspector looked at records and also toured the building. The home was running efficiently during the visit. The staff rapport towards the residents was friendly and relaxed. The residents were in various areas of the communal rooms and some were in their bedrooms. The home was clean and tidy and well maintained. Residents received regular activities, which is organised by the activities organiser. The comments received included the way they felt cared for by the staff, their well maintained environment, their close proximity to their families who are able to visit regularly and their friendships they have made in the home itself. The staffs were very supportive towards each other. The inspector wishes to thank all the residents and the staff for their warm welcome and hospitality on the day and for their contribution to this report. What the service does well: The comments made to the inspector during conversations with the residents evidenced that they were happy living in Hatch mill and felt comfortable. They had nice bedrooms and were able to bring in many pieces of furniture and personal items when they moved in. They were encouraged to pursue any activities and maintain contact with friends and family, go out and receive visitors. The food is reported as tasty. The interactions between staff and residents were friendly and respectful. Staff knew their needs well and responded to them in a knowledgeable and competent manner. The environment was tidy and well maintained. The home was running well. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: These issues were raised during this inspection and requirements were made as a result: 1. The heating system was not working adequately and efficiently. At least 3 residents stated that they felt it was colder than usual. The manager and general manager did take action to rectify the issue with immediate effect. (Standard 25 and 38) 2. Training in care planning must be offered to staff that worked on the residential floor for consistency of documentation and for adequate details to be documented in care plans. (Standard 7 and 30) 3. Care plans need to be more detailed. (Standard 7) A recommendation was also made for the blue telephone cables in one office on the ground floor to be covered with an appropriate protective cover. (Standard 38) Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 7 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. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 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.V277610.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was assessed during the inspection in June 2005. Please refer to the previous report for details. The inspector was advised that there had been no changes to the admission procedures. EVIDENCE: Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 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 the following standard(s): 7 and 9 All residents had a care plan which contained information relating to their care needs. There is work to be done for consistency of the detail of documentation in care plans as they varied from those residents who received personal care and those who received nursing care. There was evidence to suggest that the staff on the residential side would benefit from training in care planning. Medication policies and procedures were present and were followed. EVIDENCE: Standard 7: Three care plans were selected at random. On average the care plans for those receiving nursing care offered detailed information about care needs whereas the ones for residents who received personal care offered basic information. Two requirements were made regarding care planning: 1. Training must be offered to staff who worked on the residential floor for consistency of documentation and for adequate details to be documented in care plans. 2. The care plans need to be more detailed. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 11 However risk assessments for falls, moving and handling and nutrition were there on all care plans. There was a need for meaningful information to be documented on some care plans and for staff to understand why phrases such as, “care given as planned” was not sufficient and meaningful on the residential care side. The daily notes on the nursing units did provide good detailed information and it was easy to track details and follow up any event on each shift. Standard 9: The home had policies and procedures for the management of medication and training is offered for all those who dealt with medication. Storage was appropriate and adequate. Medication records were in good order. There was regular sampling of those by the manager and the general manager. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 12 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): This section was assessed during the inspection in June 2005. Please refer to the previous report for details. The inspector was advised that there had been no changes. EVIDENCE: Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 13 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): 16 and 18 The home has procedures to deal with complaints and for referring any suspected cases of abuse under the vulnerable adults procedures. EVIDENCE: The home had a complaints procedure and there are a number of persons who are either employed or worked in voluntary capacity to advise the society who can deal with listening to residents and their visitors and resolving any issues whey they rise. The manager stated that the home was pro-active to responding to complaints and she was available most days and spoke to residents individually on a daily basis. The home uses the Surrey Multi-Agency Policy and Procedures for the protection of vulnerable adults (POVA). Staff were police checked prior to commencing work. All staff received regular updates in POVA. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 14 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): 25 This section was assessed during the inspection in June 2005 and comments can be seen on the previous inspection report. However there were issues relating to the heating in some areas of the home which needed urgent attention during the inspection. EVIDENCE: Standard 25: The heating system was not working adequately and efficiently, as also stated under Standard 38. A requirement was made for the registered providers to ensure that the heating system throughout the home works adequately and efficiently. At least 3 residents told the inspector that they felt cold and indeed in the inspector’s opinion too, there were varying temperatures felt as one walks in the several areas of the large home. The manager and the general manager did take the issue seriously to rectify with the maintenance team. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 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): 27 and 30 The home employs adequate numbers of registered nurses and care staff to run efficiently. There are support teams for cleaning, general maintenance, laundry and catering in place. The home offers a good training package for all levels of staff and was required to provide training in care planning. EVIDENCE: Standard 27: The home employed sufficient numbers of staff to run efficiently. The only changes in recent weeks related to two registered nurses resigning and whose hours needing to be covered. There are currently vacancies for 2 part-time registered nurses. A relief nurse is currently covering the hours until replacements are in place. Standard 30: The home does offer a good training package for all levels of staff including all mandatory training in health and safety, moving and handling, risk assessments, fire, POVA, First Aid and several other training for the registered nurses. During the assessments of care plans it was required that care planning training (Standard 7) be offered to those who worked on the residential side of the home to ensure better consistency and detail in documentation. Hatch Mill DS0000013663.V277610.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): 33 and 38 There was evidence that the residents were well care for and that the home made every effort to ensure that it ran in the best interest of its residents. The residents’ monies were held in accordance with the home’s procedures to ensure they were safeguarded from financial abuse. The home’s procedures for health and safety were good. EVIDENCE: Standard 33: Residents spoke directly to the inspector and stated that they felt they were looked after well. The home responded to any comments and suggestions made from relatives and during residents’ reviews in a positive and proactive manner. They have actioned all requirements made during previous CSCI Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 17 inspections and showed genuine concern for ensuring that they met all the National Minimum Standards for Older People. Staff reviewed the care of residents regularly including their care plans and interests for participating in activities inside the home and externally. The home received a visit at least once a month from a representative on behalf of the registered providers and their comments are sent to the CSCI and the registered manager to report on the conduct of the home in accordance with Regulation 26 of the Care Homes Regulations. There are a number of persons who also worked in voluntary capacity to advise the board and also report on any issues. Standard 38: There were procedures for health and safety. Staff received training in all relevant aspects of health and safety including fire, basic food hygiene, first aid and infection control. Repairs were undertaken promptly by the on site maintenance man. External contractors regularly serviced all equipment for fire, hoisting, bathing, catering and clinical appliances. During the tour of the premises the following health and safety issues were noted: As stated under Standard 25 a requirement was made for the registered providers to ensure that the heating system throughout the home works adequately and efficiently. At least 3 residents told the inspector that they felt cold and in there were varying temperatures felt as one walks in the several areas of the large home. The manager and the general manager did take the issue seriously to rectify with the maintenance team. The inspector noticed a large uncovered box of blue wires on a wall in the office used on the day of the inspection. It was unclear why the box was left exposed without cover and whether this was appropriate. It was recommended that the registered persons assess this as it did it look out of place in an office. The manager and the general manager explained that the box housed telephone cables and that previous discussions had taken place but no real outcome reached as to the reasons for these cables to be left exposed. A recommendation was made for the box to be covered with an appropriate cover. Hatch Mill DS0000013663.V277610.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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 2 X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Hatch Mill DS0000013663.V277610.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. 1. Standard OP25 Regulation 23 (2) (p) Requirement Timescale for action 2. OP7 15, 30 Ensure the heating in the home is in working order at all times 30/01/06 and any issues rectified as soon as it is noticed. The care plans need to offer more detailed information about 31/03/06 each individual resident’s holistic needs. Offer training in care planning to staff that worked on the 30/04/06 residential floor for consistency of documentation and for adequate details to be documented in care plans. 3. OP7 15, 18 (1) (c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 20 1 OP38 It is recommended that the blue telephone cables in one office on the ground floor be covered with an appropriate protective cover. Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Easing Surrey GU7 2QN 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 Hatch Mill DS0000013663.V277610.R01.S.doc Version 5.1 Page 22 - 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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