Inspection on 25/04/05 for Hatherley Care Home

This inspection was carried out on 25th April 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 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

Hatherley Care Home 28/09/07

Hatherley Care Home 25/10/06

Hatherley Care Home 21/12/05

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 25th April 2005 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 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 I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hatherley Care Homes Address Chaters Hill, Saffron Walden, Essex, CB10 2AB Telephone number Fax number Email 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 24 registration, with number of places Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03.03.05 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 people. 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 recently been sold to Hatherley Care Homes Ltd. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 25th April 2005, and took place over 6 hours. Thirteen of the thirty eight National Minimum Standards were inspected: one exceeded, ten were met, one was nearly met and one were not met. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with the manager, two residential care coordinators, three staff including the cook, a visiting district nurse, one relative and five residents. The tour of the premises included observation of seven bedrooms, all of the bathrooms and toilets, the communal areas and the laundry. There was an opportunity to spend a considerable 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 home provides a warm and friendly atmosphere for residents. The furnishings and decoration are of a good standard. The staff in the home are enthusiastic and committed to providing good quality care. The staff are friendly and approachable, and have built positive relationships with both residents and relatives. The food provided by the home (as evidenced by the menus) is varied and nutritious. Residents commented that the food is: “good” they had “plenty of choice” and two residents stated that they had “more than enough”. The residents’ healthcare needs are closely monitored and speedy referral is made to appropriate healthcare professionals as required. The district nurse spoken with reported that the staff were able to follow advice, and that the staff regularly contacted the GP and district nurses to refer for treatment. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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 standard(s) 1, 3, & 4. The home provides clear and detailed information to prospective and current residents. There is an effective pre-admission process that ensures that the home can meet the individual’s needs and results in appropriate admissions. The service is able to meet the needs of the residents living there. EVIDENCE: The home’s newly developed Statement of Purpose and Service User Guide contained all of the required information. The staff who developed both documents are to be commended for their efforts. Four care plans were sampled and all of these contained the information required for an appropriate and effective admission into the home. Full social services and/ or hospital assessments were found on the files along with the home’s own pre-admission document. The home’s pre-admission assessment did not include all aspects of the resident care needs. Two residents who had recently moved into the home commented that their families had visited the home on their behalf, and stated that the staff had been very “kind and considerate” since they moved into Hatherley. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 9 There was evidence that a good level of staff training was being provided in Hatherley. The staff spoken with demonstrated a good understanding of the individual and collective needs of the residents. All residents spoken to were very positive about the care provided at Hatherley, and felt confident that the staff had the skills to deliver the support and care that they required. One resident commented that they felt that the staff “knew what they were doing”. Hatherley did not provide an intermediate care service. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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 standard(s) 8 & 10. The residents’ healthcare needs are well met in Hatherley. The residents’ care plans are detailed and directive. The staff have a sensitive and caring approach toward residents and treat them with respect. EVIDENCE: Four care plans were examined and all of these contained clear and detailed instructions for the delivery of personal care for residents. Oral healthcare was detailed in the care plans. Routine health checks offered such as optician, dentist, and podiatrist were well documented. The home provided residents with access to aids and equipment to address their healthcare needs and issues. The manager stated that the home is well supported by the local primary healthcare team. The care plans contained additional information that included moving and handling, pressure care, and continence assessments. Two service users stated that they were confident that staff would take the “right decision when they were ill” and that “the staff always contact my family when I am poorly”. The District Nurse available for comment, stated that the standard of care provided at Hatherley was good, that the staff were experienced and responsive to instruction from healthcare professionals. The district nurse Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 11 continued by confirming that they were confident in the skills of the staff to identify and refer healthcare issues to the appropriate healthcare service. Four of the residents spoken with commended the staff with regard to the treatment they received in Hatherley. The residents stated that their privacy and dignity was maintained in a variety of ways, including the way staff provided 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 were friendly, considerate and respectful toward residents. Residents commented that the “staff are wonderful” and “respected me as a person, even when I am having a bad day”. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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 standard(s) 12 & 15. The home provides an appropriate range of activities for residents. Routines in the home are flexible and residents are enabled to exercise choice. The home provides the residents with a varied, nutritional and well-balanced diet that addressed specific individual need. EVIDENCE: Routines in the home appeared flexible and residents’ individual choices were addressed. One resident commented that they felt that they were “free to come and go as I pleased”. Staff encouraged residents to leave the home with relatives, and “would make them their dinner or a snack” upon their late return to the home. Two residents confirmed that there was a programme of activity and that “there was always something going on” and “always something to do if I was bored”. Regular social events take place and residents confirmed that they were consulted regarding the entertainment brought in from the outside. The relative of a resident commented that their relative would benefit from being taken out of the home for a walk, and this action was agreed by the manager at the time. This relative commended the home and the staff for the “fantastic care” that was provided to their relative. They felt that they were “welcome in the home at any time” and that there views were valued and taken note of. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 13 Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 14 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 standard(s) 16 The home provided residents and relatives with a thorough and comprehensive complaint policy and procedure that enabled them to make a complaint. EVIDENCE: The home had a newly developed Complaint procedure that was both clear and concise. The document directed the individual on how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was written in plain language and was user friendly. Three residents confirmed that they were not aware of the existence of the Complaint procedure, however they were able to confirm that they knew who to complain to, and felt confident that their concerns would be dealt with immediately. The relative spoken with was able to confirm that they were aware of the Complaint Proceduere and this had been introduced by a member staff. The home’s complaint log was well maintained and up to date. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 15 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 standard(s) 19 &25. The home is homely, safe and well maintained; heating and lighting were generally satisfactory. The home did not have suitable water temperature systems in place to ensure the safety of residents when bathing. The home was clean and hygienic; there are systems and facilities in place to prevent the spread of infection. EVIDENCE: Hatherley is a large detached property that has been adapted to meet the needs of older people. The building is well maintained and decorated and furnished to a good standard. The residents comments regarding the environment included: “I always feel safe when I am having a bath”, “the home is always clean and tidy” and “the staff work hard to keep the home clean and my bedroom always smells nice”. On tour of the premises all areas of the home were clean, tidy and free from odour. The temperature of the hot water from the taps in the bathrooms is too hot, and were being recorded at near to 50 degrees, which places residents at Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 16 risk. From examination of the documentation relating to the weekly hot water temperatures it was noted that this issue had been ongoing for at least two months. An immediate requirement notice was issued requiring the manager to take urgent action. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The home provided an appropriate training and development programme that ensured that staff to have the skills necessary to do their job and care for residents appropriately. EVIDENCE: A senior member of staff in the home has been delegated to develop the staff training and development programme. Individual training records and evidence of Induction training were not inspected on this occasion. The training programme recorded both recent and planned training and included dementia, moving and handling, infection control, and care planning training. (In addition to core training requirements). The member of staff responsible for developing the programme must be commended for the effort made to create a comprehensive and focussed plan of training. Regarding NVQ training, currently fifteen staff have achieved NVQ level 2, while a further five are undertaking the course. Residents spoken with reported that the staff were able to address their varying needs with care and sensitivity. The residents were complimentary regarding the skills and knowledge of the staff and stated that the staff were “very kind and caring”. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35. The home did not have a system for measuring the extent to which it is meeting the needs of individual residents. The residents financial interests are safeguarded in the home. EVIDENCE: Hatherley does not have a quality assurance programme in operation. The home does not act as appointee for any resident living there. Two resident’s financial issues continue to be dealt with by Essex County Council and accounts are held at County Hall (Chelmesford). The families of the majority of residents undertake the responsibility for finances. Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 1 x 3 x x x Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? 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 13 (3) (4) Requirement The registered person must take immediate action to ensure that hot water is delivered at a safe temperature. The registered person must ensure that all documentation relating to the recruitment of staff id available for inspection. This standard was not inspected and remains outstanding. The registered person must ensure that a quality assurance system is implemented in the home. Timescale for action 30.05.05 2. OP29 17 (3) (b) 30.06.05 3. OP33 24 (1) (a) (b) 24 (2) 30.06.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Hatherley Care Home I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Fairfax House Causton Road Colchester 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 I05-I56 s62235 Hatherley Care Home v226103 250405 stage 4.doc Version 1.30 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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