CARE HOMES FOR OLDER PEOPLE
Hatfield Haven Stortford Road Hatfield Heath Bishops Stortford Essex CM22 7DL Lead Inspector
Sharon Thomas Unannounced Inspection 17th October 2005 09:30 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 Hatfield Haven DS0000017843.V261746.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. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hatfield Haven Address Stortford Road Hatfield Heath Bishops Stortford Essex CM22 7DL 01279 730043 01279 730043 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) Hatfield Haven Limited Manager post vacant Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 18 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 18 persons) The total number of service users accommodated in the home must not exceed 18 pesons Service users must not be admitted to the home under the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 Date of last inspection Brief Description of the Service: Hatfield Haven is a large detached house. The home is located on the edge of the village of Hatfield Heath that provides access to public transport and shopping facilities. The home has two managers who are applying to the Commission for Social Care for registration. The home is registered to provide residential accommodation for 18 older people (over the age of 65, with dementia), with low to high dependency needs. Hatfield Haven aims to provide individually tailored care and to meet the physical, social and emotional needs of the individuals who live there in a warm and homely environment. The home has bedrooms located on both the ground and first floor of the premises; the upper floor is accessible through the passenger lift. The homes grounds are accessible to both the service users and their visitors. The home is well equipped to meet the needs of the current service user group and provides aids and adaptations to assist service users with limited mobility. The home benefits from a well-trained and sensitive staff group who had a sound knowledge of the service users and their needs. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 18th October 2005, over 12 hours. Two inspectors Sharon Thomas and Ray Finney undertook the visit. Ten of the thirty-eight National Minimum Standards were inspected: four were met, five were nearly met and one was not met. For the purpose of this report the individuals spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with the managers, three members of staff, and two residents. The partial tour of the premises included observation of seven bedrooms, all of the bathrooms and toilets, all of the communal areas, the kitchen and the laundry. There was an opportunity to spend a period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home was warm, clean and tidy. The residents spoke highly of the care that they receive in Hatfield Haven and spoke highly of the efforts of the staff. The home has close links with the local primary health care team, and works with professionals and service users to promote the health of the residents. What the service does well:
The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that all of the residents spoke about. Hatfield Haven has a good caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic and skilled. All of the residents spoken with on the day stated that the managers and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: 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. Hatfield Haven DS0000017843.V261746.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 Hatfield Haven DS0000017843.V261746.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): None of the above standards were inspected please see previous report. EVIDENCE: Hatfield Haven DS0000017843.V261746.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): 7, 9, & 10. The care plans used in the home do not contain information on all aspects of care and the risk assessments do not identify all areas of risk. The administration records of medication are not well maintained, and have the potential of placing residents at risk. The home provided a service that treated the residents with respect, staff engaged positively with residents and demonstrated a good understanding of their needs. EVIDENCE: Three residents’ care plans were examined on the day of the inspection. The care plans contained information on physical, social, emotional care, and manual handling. Overall the care plans have greatly improved since the last inspection, however they need to be developed to include details of all aspects of care. All of the records examined had limited detail about social interests and activities. One care plan had a record of dates of G.P. and District Nurse visits, but there were no further details of healthcare needs. On the whole, risks were not well identified in the care plans. One care plan had a ‘behaviour management’ plan in place but descriptions of behaviours were insufficient to ensure that care was given and behaviours were managed in a consistent way. Some of the language used in the ‘behaviour management plan’ was
Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 10 inappropriate and focussed on negative aspects of situations that had happened. Records examined showed that care plans had not been signed by relatives or advocates and there was no evidence of input from representatives. If residents did not have the ability to make decisions for themselves, this was not identified in care plans. Records examined showed that care plans were reviewed regularly. The home had a comprehensive medication policy and procedure for the administration of medication. One service user in the home was able to self medicate, the care plan contained a risk assessment, and the home had provided lockable storage. The medication in the home was secure on the day of inspection. The medication cabinet was locked and secure. The home used the local Boots chemist and used a monitored dosage system. The medication administration records were not accurately maintained and there were gaps in the recording. The home accurately recorded the receipt and disposal of medication. The controlled drugs register was examined and was accurate, the home did not have a separate controlled drug cabinet in use. The staff received regular refresher training with regard to medication. However this was provided internally and external training from Boots should be arranged on a regular basis. The staff spoken with were aware of the use and side effects of medications and felt confident when giving medication. During the inspection the staff were observed giving a friendly and respectful service to residents. The staff spoken with confirmed the importance of privacy and dignity and discussed how they maintained these issues in their daily care practices. Staff stated that these issues were introduced in a variety of training. Residents spoken to report that staff were “patient and kind,” they assisted residents to preserve their dignity and assisted them with their personal care needs in a professional manner. One resident confirmed that they had made a choice regarding who they wanted to assist them with their personal care needs and that this choice had been supported by the staff Hatfield Haven DS0000017843.V261746.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): 12 & 13. The home does not provide an environment that meets the social and recreational preferences of the residents. The home encourages residents to maintain contact with relatives and friends and the local community. EVIDENCE: Hatfield Haven has a dedicated activity co-ordinator who works 20 hours a week. The activity programme was not available on the day but there was evidence that outside entertainment was offered. The care plans looked at did not fully detail the social and recreation needs of the residents. There was no evidence to suggest that individual religious needs were being met. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. Mealtimes were flexible as observed on the day of the visit. Staff spoken with confirmed that residents see relatives and professionals in private. Visitors to the home are welcomed at any time and there are no restrictions on visiting time. External entertainment is provided in the home and this was displayed in the foyer. The staff confirmed that residents choose who they wish to see and when.
Hatfield Haven DS0000017843.V261746.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): 16 Overall the home had an effective complaint procedure that enabled residents and relatives to make a complaint. EVIDENCE: The home’s recently developed complaints procedure was examined. It was prominently displayed in the entrance hall and copies were available. The complaints procedure contained a timescale for responding to the complaint and there were details of The Commission for Social Care Inspection and an address to write to. Records examined showed that one complaint had been recorded since the last inspection, but there was not enough information recorded about the outcome of the complaint and whether it had been resolved to the satisfaction of those who had complained. Hatfield Haven DS0000017843.V261746.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): 26 The home was clean, warm and had high standards of hygiene. EVIDENCE: The home’s laundry facilities are located away from communal areas and individual bedrooms reducing the risk of cross infection. The equipment in the laundry is suitable for the needs of the residents. Residents and staff confirmed that their clothes were returned from the laundry “smelling nice and well ironed”. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 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): 29 The recruitment procedure in the home was not robust and did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The management team spoken with on the day of the inspection explained that the recruitment process was led by a staffing agency. The Human Resources manager and one of the home’s management team conducted interviews. The management team were aware of the relevant checks that were required around the Protection of Vulnerable Adults and Criminal Records Bureau enhanced disclosures. The management team stated that new staff were given the General Social Care Council Code of Conduct when they started work. At the time of the inspection, there were no volunteers working in the home. A sample of three staff files was checked on the day of the inspection. Overall, files were found to be incomplete and not all documents that are required to be kept were in place. Two of the staff files examined did not contain photographs. On two files, the dates of previous employment were unclear or not documented, making it difficult to check for gaps in employment. A ‘contents checklist’ was attached to the front of each staff file, but this was not complete on any of the files examined and there was no evidence that missing documentation was followed up. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 15 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. The home has joint managers who are applying for registration. The home safeguards the resident’s financial affairs. EVIDENCE: The home has two managers who have individual responsibilities of care. The managers have a long and established experience in care. The inspection highlighted that that the managers did not have experience in management and that they would need increased support to reach the requirements of the Care Homes Regulations 2000 for registered managers. The home does not manage any resident’s financial affairs. If the resident does need money, the home will pay for goods and services and invoice the relative or representative. Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 16 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X 3 X X X Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 17 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 Standard OP7 Regulation 15(1)(2) (c)(d) Timescale for action The registered person must 30/11/05 ensure that individual care plans contain all of the required information to enable the safe delivery of care. The care plans must record the issue the action and the outcomes of care. This is a repeat requirement from 21.10.04 and 13.04.05 The registered person must 30/11/05 ensure that individual care plans contain an up to date risk assessment that identifies all elements of risk and action to address these needs. This is a repeat requirement from 21.10.04 and 13.04.05. The registered person must 30/11/05 ensure that individual care plans contain evidence that residents and relatives are involved in the care planning process. The registered person must 30/11/05 ensure that individual care plans contained detailed information relating to the residents health care issues. The information must be updated to reflect when a change in need has occurred.
DS0000017843.V261746.R01.S.doc Version 5.0 Page 18 Requirement 2 OP7 12 (1)(a) 3 OP7 15 (1) 4 OP7 12`(1) Hatfield Haven 5 OP9 13 (2) 6 OP12 14 (1) (a) 7 OP29 7,9,19,(1) Sch 2 8 OP30 18(1c)(i) (ii),12(1) The registered person must ensure that the records of the administration of medication are accurate and up to date. The home must have a separate controlled drug cabinet available for controlled drugs. The registered person must ensure that an appropriate activity programme is in place that meets the needs of the residents. The registered person must ensure that the home has a robust recruitment process. The registered person must ensure that all appropriate checks are undertaken prior to appointment to ensure the safety of the residents. The registered person must ensure that the home has a staff training and development programme and must maintain training records for inspection. This requirement was not inspected on this visit and will be carried over until the next inspection. This standard was not inspected and is carried over from the previous inspection. 17/10/05 30/11/05 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hatfield Haven DS0000017843.V261746.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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