Inspection on 21/12/05 for Hatherley Care Home

This inspection was carried out on 21st December 2005.

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

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

Other inspections for this house

Hatherley Care Home 28/09/07

Hatherley Care Home 25/10/06

Hatherley Care Home 25/04/05

Hatherley Care Home 07/03/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hatherley Care Home Chaters Hill Saffron Walden Essex CB10 2AB Lead Inspector Sharon Thomas Unannounced Inspection 21st December 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 Hatherley Care Home DS0000062235.V275292.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. Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hatherley Care Home Address Chaters Hill Saffron Walden Essex CB10 2AB 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) 01799 508080 01799 508081 Hatherley Care Home Ltd Lorna Margaret Law Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 24 persons) 25th April 2005 Date of last inspection Brief Description of the Service: Hatherley is a large period building; it has three storeys with lift access for residents. The accommodation for residents is situated on the ground and first floors. The home provides care to meet the physical, social, and emotional needs of residents. The home has been adapted to meet the needs of residents with limited mobility. The manager and staff work hard to create a homely atmosphere, where choices are valued, and rights preserved. The home was well decorated and well furnished throughout. The home provided pleasant communal lounges and a large dining room. The grounds were attractive, well maintained and provided adequate parking space for visitors and staff. The home has been sold to Hatherley Care Homes Ltd. Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second for the 2005 to 2006 inspection year. This inspection took place on 21st December 2005, and took place over 4 hours. Sixteen of the thirty-eight National Minimum Standards were inspected: eleven were met, four were nearly met and one not met. For the purpose of this report the individuals living in the home will to be referred to as residents. The inspection process included: discussions with the manager, one residential care coordinator, one resident and two members of staff. The tour of the premises included observation of four bedrooms, all of the bathrooms and toilets, the communal areas and the laundry. There was an opportunity to spend a period of time observing the care being provided by the staff. The inspection covered 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 and comfortable with good furnishings and a high level of decoration. The residents were well cared for by a team of well-trained, skilled staff. What the service does well: The service works well at ensuring that the home is decorated to a good level and is homely in nature. The routines in the home are as flexible as possible and are changed to the meet the varying needs of the residents. Relatives and visitors are welcomed into the home and residents felt that the home encouraged their relationships. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. The health and safety of both residents and staff is maintained through appropriate training and assessments of the premises and the residents. Hatherley has a caring staff team, and the home has a low staff turnover. The staff team are enthusiastic, well trained and skilled. Staff are cheerful, Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 6 attentive and keen to provide a good service. The standard of care is good, and the resident spoken to was happy with the way they were cared for and felt relaxed in their surroundings. What has improved since the last inspection? What they could do better: The home’s pre-admission assessment document does not contain all aspects of care necessary to a safe admission. The records of the administration of controlled drugs are not accurately maintained. This could have the potential of placing residents at risk. The home does not have satisfactory policies and procedures regarding the protection of vulnerable adults. The home has not analysed the results of the residents/relatives quality assurance surveys. The home did not have the annual business and financial plan available for inspection. The home is currently reviewing the budgets, however indications are that this is not adequate to meet the needs of the service. CSCI will be discussing this issue separately with the provider. Hatherley Care Home DS0000062235.V275292.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. Hatherley Care Home DS0000062235.V275292.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 Hatherley Care Home DS0000062235.V275292.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): 3 & 6. Overall the home has an effective pre-admission system in place that ensures that every prospective resident had their physical, mental, emotional and social needs assessed. Hatherley does not provide intermediate care. EVIDENCE: The manager, to establish the needs of the individual, undertook the preadmission assessment. The care plans examined indicated that residents or relatives are involved in the assessment of need. The home’s pre-admission assessment document was comprehensive but it did not identify all aspects of the individual’s care needs. The gaps were identified with the manager and the manager agreed to develop the document. One resident spoken with confirmed that prior to their admission their family had been fully involved with all decision making about their care. Hatherley Care Home DS0000062235.V275292.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, 9. & 10. Overall the home’s care planning systems are satisfactory. The care plans indicated that the residents care needs are identified, planned for and monitored in an appropriate manner. Overall the administration of medication is safe. The home provides a service that treats the residents with respect, staff engage positively with residents and demonstrate a good understanding of their needs. EVIDENCE: Three care files were examined. All three contained detailed information regarding the resident’s needs, the action to address the needs, and the longterm outcome of the care given. The care plans covered all aspects of a resident’s physical, mental and social needs, and were reviewed on a monthly basis. There are detailed risk assessments and manual handling assessments. There was evidence that residents signed care plans and are involved in the planning process. One care plan did not have a photograph of the resident in place. The daily records looked at were of a poor standard and did not record the actual care given by staff. Residents commented that the staff knew “the little things about me” and that staff “do a very good job to look after all of us”. Staff were observed treating residents with care and sensitivity. Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 11 No resident living in the home was able to self medicate. The medication held was securely locked away on the day. The records of the administration, receipt, and disposal of medication are accurate and well maintained. However, the records of controlled medication had one gap in the recording. The staff spoken with that were responsible for giving medication confirmed that they had received appropriate training and support, and are confident that they ensured the safety of the residents when giving medication. Staff reported that they had a good working relationship with the pharmacist and are able to contact him to seek advice if required. Staff were observed treating residents with care and sensitivity, addressing residents appropriately and demonstrating a genuine level of care. The staff stated that residents’ privacy and dignity was maintained in a variety of ways, including the way that they provide personal care, toileting issues, respect for visitors, and the provision of private areas in the home that enabled residents to see visitors in private. Observation of staff during the inspection indicated that staff are friendly, considerate and respectful toward residents. Residents commented that the “staff are wonderful” and “respected me as a person” and “treat me with respect at all times”. Hatherley Care Home DS0000062235.V275292.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): 13 & 14. The home provides the residents with variety and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are well met, and the capacity of individual residents to make choices is central to the care provided in the home. EVIDENCE: The manager confirmed that the home does not act as appointee for any of the residents living there. One resident was able to manage their own finances and this was encouraged by the home. Arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions are available. The care plans examined indicated some personal preferences in terms of food, clothes and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. One resident commented that they felt that they were “free to come and go as I pleased”. Staff confirmed that they encouraged residents to leave the home with relatives, and encouraged relatives to attend events held in the home. Hatherley Care Home DS0000062235.V275292.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): 18. The home did not have a clear or robust system in place that ensured the protection of residents in the event of an allegation of abuse. This has the potential of placing residents at risk. EVIDENCE: The adult abuse policy and procedure was not suitable for the purpose of protecting vulnerable adults. The document had little detail regarding the signs or types of abuse and did not contain clear or detailed information for staff. The home did not have a whistle blowing policy available to staff. The training records reviewed on the day confirmed that all staff except the new staff had received adult abuse training. However, following the inspection the CSCI received confirmation that all staff had in fact received the appropriate training. The manager had not been aware that the new recruits to the home had been provided with this training and this issue was discussed in relation to the fact that the manager must be aware of these matters. The manager reported that the home had not had any allegations of abuse since the previous inspection. Hatherley Care Home DS0000062235.V275292.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): 26. The home provides residents with a safe, well decorated, and well furnished place to live. 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. The home has one sluice in operation and this was clean and well maintained. Residents confirmed that their clothes were returned from the laundry “smelling nice and well ironed”. Hatherley Care Home DS0000062235.V275292.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, 28 & 29. Staffing levels (number and competence) meet the needs of current residents. There is a stable and loyal staff team, which ensure consisitency in the delivery of care. The recruitment procedure in the home was robust and ensured the safety and protection of the residents. EVIDENCE: The staff rota examined reflected that the home was providing the agreed levels of staff. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. The proprietor has met with the inspector prior to this inspection to discuss staffing levels. The proprietor and the inspector agreed that the staffing hours being provided were slightly above what was required. Records confirmed that 10 members of staff in the home had achieved the NVQ Level 2 qualification, funding for Polish staff was being applied for. The staff personnel files of the two newest recruits to the home were examined on the day. These both contained all of the information needed to ensure the safety of residents through the recruitment process. They contained a POVA first/Criminal Reference Bureau check, three references, a photograph of the Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 16 member of staff and personal ID. Staff had received a contract of employment and a copy of the General Social Care Council Code of Conduct for staff. Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 17 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, 33, 34, & 38. Hatherley has a competent, reliable and professional manager who is fit to meet the purpose of the role. The home has systems in place to ensure that the quality of care is measured and acted upon. The residents are not fully safeguarded by the financial procedures in the home. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: The staff on the day confirmed that they were confident in the skills of the manager. The manager has built good relationships with the staff team. The manager Lorna Law has many years experience in social care and had been the registered manager of Hatherley for the past 2 years. The manager had signed up to undertake the NVQ Level 4 and is due to complete the course in 2006. The manager produced records that confirmed that she undertakes appropriate refresher training. The manager is knowledgeable, skilled and Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 18 professional in her manner to residents and staff. Mrs. Law has built a positive working relationship with the inspector and will contact the CSCI for advice and information when necessary. Although the standard regarding quality assurance was not fully inspected, records confirmed that the home has completed resident and relative questionnaires. The results of the survey have not been analysed and the manager agreed to send the results to the CSCI when completed. As previously noted the proprietor had requested a meeting with the CSCI regarding staffing levels. During the inspection it was found that the home did not have an annual business and financial plan. The monthly budget records were reviewed and it appeared that the home’s budget was inadequate. The manager confirmed that although savings have been made they have not had a negative impact upon the residents. The home has appropriate levels of employee liability insurance. The insurance certificate for Business Interruption was not available for inspection on the day. The inspector requested that the manager send a copy of this certificate to the CSCI. A copy of the certificate for building & contents and business interruption was sent to the CSCI in January 2006. The home provided staff with appropriate Health and Safety training. However, fire safety and first aid training had not been provided in the home in the previous year. Risk assessments of the premises were completed and regular Health and Safety checks of facilities and equipment were also undertaken. The manager was aware of relevant Health and Safety legislation and was committed to the welfare of both the residents and staff group. Hot water, fire alarm and equipment checks were accurate and up to date. The staff spoken with are committed to the safety of the residents and are able to discuss the potential hazards in the home. The staff stated that they would report any safety hazard to the manager who would take the appropriate action. The staff also confirmed that they would use the resident risk assessment to ensure the safety of the residents. Staff are aware of Health and Safety issues around the home and wear personal protection clothing when needed. Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 19 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 1 X X X 3 Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 20 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 OP3 Regulation Schedule 3 (1) (a) Timescale for action The registered person must 28/02/06 ensure that the home’s preadmission document is developed to identify all aspects of future care. The registered person must 21/12/05 ensure that records of the administration of controlled drugs are accurate and well maintained. The registered person must 28/02/06 ensure that the home’s adult abuse policies must be developed. These must contain comprehensive details on the issue, and direct staff on the appropriate action to take when required. The registered person must develop a whistle blowing policy and make this available to staff. The registered person must 28/02/06 ensure that the results of the quality assurance surveys are analysed, acted upon and published. The registered person must 28/02/06 provide information to confirm and ensure the financial viability DS0000062235.V275292.R01.S.doc Version 5.1 Page 21 Requirement 2. OP9 13 (2), 17 (1) (a) 3. OP18 12 (1), 13 (6), 21. 4. OP33 24 (1) (a) (b) 5 OP34 25(2)e Schedule4 Hatherley Care Home of the home. An annual business and financial plan must be forwarded to the CSCI. 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 Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 22 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 © 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 Hatherley Care Home DS0000062235.V275292.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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