Inspection on 28/09/07 for Hatherley Care Home

This inspection was carried out on 28th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 25/10/06

Hatherley Care Home 21/12/05

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 Sarah Hannington Unannounced Inspection 28th September 2007 11:00 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 Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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 sabita@hatherleycare.wanadoo.co.uk Hatherley Care Home Ltd Lorna Margaret Law Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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 27 persons) 25th October 2006 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 are attractive, well maintained and provided adequate parking space for visitors and staff. The home has recently refurbished space to increase the number of available bedrooms by three. The home’s current charges are £440.72 per week per bed. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit inspection mainly focused on all Key standards. The inspection took 4 hours to complete. The registered manager is currently off on long term sick and the deputy manager has stepped up into the management role for the past six months. This manager was present through the inspection. Prior to this inspection CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties. Information collated from surveys and discussion during the site inspection will be reflected within this report. Additionally the manager was sent a (AQAA) Annual Quality Assurance Assessment form by CSCI (Commission for Social Care Inspection) that asked how well the home is meeting the needs of the people who live at Hatherley Care Home. We also looked at what else we already know about the home and compare it with what the proprioter had said the information provided on the (AQAA) documentation we received back. During the site visit one visitor, fifteen residents and six staff were spoken with during this process. There was also a tour of the premises. What the service does well: What has improved since the last inspection? Both requirements from the last inspection have been met. A new bathroom has been fitted with an overhead hoist. A visitor’s room has been provided. A new small lounge has been created. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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 Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has clear information setting out the homes aims, objectives and services provided. Prospective residents are formally assessed prior to admission. EVIDENCE: The policies and procedures of the home provide evidence that it meets the requirements expected for the admission of any new resident. A statement of purpose, service users guide and the last Inspection report is available before visiting the home. These documents enable a potential resident to look at what facilities the home provides, information about the staff team, qualifications, experience and other useful information they need to know to make a judgement that the home is one they would wish to live in can meet their needs. A pre-assessment form is used by the home and a qualified member of staff will carry out an assessment of that individuals need. Additionally If a individual is referred to by a social worker initially a COM 5 is obtained before the pre-assessment is carried out or if a person is privately funded then further Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 9 information from their GP is obtained, these were evidenced within documentation looked at during the site visit. If all parties agree admission, then the new resident will firstly be offered trial visits, have a key worker allocated to them, have a four-week trail period and then a review. Part of this review will include the resident, their social worker or any relatives and representatives they may choose to have there to establish if the home is suitable and can cater for their needs. Residents and relatives spoken with confirmed they had been to visit Hatherley Care home before any admission was agreed and had been given documentation that allowed them to look at what the home can offer them. One new resident confirmed that a four-week review had gone ahead since moving in. The manager evidenced through discussion that good practice was in place around the admission procedure. No intermediate care is provided, although emergency short-term placements are considered. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans contained the information required to meet the residents’ needs. Health care needs are fully met and medication policies and procedures protect the residents. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: There is a care plan in place for each resident along side a good standard of risk assessments. There is evidence that consultation with the individual goes ahead and that their choices are included, additionally other professionals are used as a part of this process. All care plans are signed for by the resident or their representatives to show that care to be provided is agreed. Looking through care plans it evidenced that specialist services are catered for, that appropriate equipment is provided and in place for those individuals that need it. There is a good process for monitoring of falls; pressure sores and other health issues are in place. All residents have access to a GP, district and community nurse, chiropody, optician, audiologist and dental practice. Good paperwork evidenced staff liaise well with other professionals and have strong links and good partnerships with the local PCT team. Medication is stored within lockable cabinets. Controlled drugs were being maintained in accordance Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 11 with agreed procedures. Record sheets had been correctly recorded and signed for. Staff spoken with around medication issues evidenced that they were experienced, professional and competent. Staff who administer and stock check medication are all fully trained to do so. Overall the homes system for checking, monitoring, ordering, disposal and booking in of and accounting for medication are all to a good standard. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activity plans for each individual are in place and to a good standard. Relatives and friends fedback that they have regular contact with the home. A variety of regular nutritious meals are being provided. EVIDENCE: Observation on the day of the site inspection evidenced that all residents had many choices of activities. The home provides different types of activities such as bingo, board games, movie nights, outings and entertainment provided by various artists. Residents have the choice to worship their chosen religion when they want to and can have ministers visits them in private or attend services within the community. Additionally observation showed that residents had their own choice of daily newspaper, reading books, knitting, music, puzzles, quizzes and any other interests they wanted to pursue. One resident spoken with still was supported to carry out their ‘pastoral’ duties outside of the home and run a ‘newsletter’ for the home. Other residents informed me that they were encouraged to choose what they liked to do and were fully supported by staff. Staff record all activities taken, choices given and activities refused, this is good practice to evidence what the home is providing. Relatives, friends and advocates are encouraged to visit any time they wished to do so. A visitor’s room is provided along with tea and coffee facilities. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 13 Visitors are made to feel welcome, offered refreshments, lunch and dinner if they choose. One visitor (an advocate for the home) who had been visiting for many years, gave a very complementary opinion of the home and stated that they felt it was the best home around the area and that they felt that there are very high standards and good practice within Hatherley Care home. Documentation evidenced that all visits from relatives, advocates, professionals or any outside organisation is recorded. Within residents files it was noted that nutritional, diet, preference and need of individuals are noted down and that staff spoken with are fully aware of these. Kitchen staff spoken with evidenced that good practice regarding health and safety, hygiene and nutrition awareness is in place and that they were aware of individuals need. The kitchen was well maintained and food stocks were plentiful. The meals provided were to a high standard and offered residents an appealing home cooked meal, which was of high quality, nutritional, reflected individual tastes, dietary needs and were praised by all residents spoken with. Each day a choice of two meals is provided for. Alternative meals are also offered if a person had changed their mind of what is offered. The dinning room is set out nicely, presented well and menus were available for residents to look at. During lunch time observation Individuals who needed supported were aided unrushed, staff chatted and sat with residents and were seen to be caring, interactive and evidenced they knew individuals well, as well as being good at getting on with the tasks they had to do during that time period. All documentation relating to meals and nutrition in general and for the individual are to a good standard and monitoring of this is kept on a regular basis. Many of the residents spoken with expressed that they felt Hatherley care home was the nearest thing to still having your own home, own choices and be able to live the life they wanted. They also spoke highly of the staff team and felt that they had nothing bad to say about the home, staff or care provided. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good complaints procedure in place. The organisations policy and procedures and training of staff protect residents from abuse. EVIDENCE: The complaints documentation within the home is to a good standard. There have been no complaints received on the last or since the last inspection. Residents and relative feedback evidences that they are aware of how to make a complaint if they wish to do so and felt confident that any complaints would be dealt with appropriately and effectively. The complaints procedures is also contained within the statement of purpose and service users guide. Staff spoken with had a good understanding and knowledge of Protection Of Vulnerable Adults reporting procedures. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides an appropriate environment that is appropriate to the needs of the people who live there. EVIDENCE: Evidenced through documentation are good environmental risk assessments of all areas inside and outside of the building. The home employs two maintenance persons who carry out health and safety weekly, monthly and annual checks within the inside and outside environment of the home. One maintenance person is presently in the process of maintaining, repainting and renewing parts of the communal areas. Some parts of the outside of the building needs to be addressed such as the ‘facets’ and the communal garden areas in the front of the home The home is odour free, clean, homely and meets the needs of the client group. Individual rooms are personalised and well maintained. The home does consult with the resident group about improvements to be made in communal areas and individuals are consulted with regarding reHatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 16 decoration of their private rooms. Laundry facilities are well maintained and looked after, staff spoken with showed good knowledge and understanding around infection control. Documentation showed that staff have universal inflection control training and that all health and safety equipment, protective clothing is available for staff to enable them to protect both the health safety and welfare of themselves and of residents. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare needs of people living in the home. EVIDENCE: During the day of the site inspection there were sufficient staff around to support, listen and to give quality time to residents. The home has an experienced well-dedicated staff team in place. At the time of inspection, the home was fully staffed and the skills mix of the staff group was being used positively in meeting the various needs of residents. There is a good recruitment and selection policy in place and contained all necessary checks required. All staff had enhanced CRB checks. The manager has put into place a new staff training and development programme, which meets Sector Skills Council workforce training targets. Hartherley care home has more than 80 of its staff with NVQ (National vocational training) training. Regular meetings, supervision, training and handovers all support staff to give a consistent approach and quality of care towards the residents at Hatherley Care home. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required experience and competence to run the care home. EVIDENCE: The registered manager is on long term sick, however the deputy manager has took a lead role on a day to day basis and is present the manager of Hatherley Care Home. The present manager has clearly made a positive impact on the running of the home. The manager evidenced through discussion, documentation looked at during the site visit and the AQAA sent back to CSCI that she is knowledgeable, has good experience and is highly organised and efficient in her role. There is clear accountability of roles amongst the team and a strong management support system in place. The policy, procedures, support for both residents and staff maintains that their health, safety and welfare is protected. The manager leads by example and encourages the staff team to practice in Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 19 terms of a residents rights and empowerment. The home’s practice is continually changing and adapting according to individual and group need which in turn moulds the service provided. Residents are benefiting from a strong management team and the level of service is continuing to improve under her leadership. Residents finances are protected and good accountable systems are is place. The homes Quality Assurance, which is to a good standard and residents meetings partly mould the homes business plan. Overall the home provides a very person centred based service which promotes and encouarges independence of the individual. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 4 Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP19 OP19 Good Practice Recommendations The manager should ensure that the external environment specifically related to the facets, need repairing, repainting and maintaining to a good standard. The manager should ensure that the communal garden areas to the front of the home are maintained to a good standard. Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hatherley Care Home DS0000062235.V348092.R01.S.doc Version 5.2 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. 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