Inspection on 26/02/08 for Hatton Court

This inspection was carried out on 26th February 2008.

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

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

Other inspections for this house

Hatton Court 17/09/07

Hatton Court 27/04/06

Hatton Court 27/09/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Hatton Court Whitchurch Road Cold Hatton Telford Shropshire TF6 6QB Lead Inspector Janet Adams Key Unannounced Inspection 26th February 2008 10:30 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 Hatton Court DS0000064716.V356498.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. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatton Court Address Whitchurch Road Cold Hatton Telford Shropshire TF6 6QB 01952 541881 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) hatton.court@hotmail.co.uk Springcare (Hatton) Limited Christine Ann Simcock Care Home 64 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (44), of places Physical disability (6) Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a maximum of 44 Older Persons requiring nursing care, 6 can be Younger Persons with a Physical Disability, and 14 persons with Dementia. The minimum staffing levels required throughout the 24 hour day, including weekends, for service users who have low to medium dependency nursing needs is as follows: 08:00-14:00 22:00-08:00 3 Qualified Nurses Qualified Nurse 9 Care Assistants Care Assistants 14:00-22:00 3 Qualified Nurses 7 Care Assistants 2 6 Additional staff must be on duty when service users requiring high direct care provision are accommodated. This is exclusive of the manager (when he/she is carrying out managerial duties). Date of last inspection 21st September 2007 Brief Description of the Service: Hatton Court is one of several care homes owned by Springcare (Hatton) Limited. Registered to accommodate a maximum of 64 Residents who may require personal care or nursing and may specifically comprise up-to a maximum of 44 ‘Older Persons’ requiring nursing care, up to 6 ‘Younger’ Persons with a Physical Disability’, and up-to 14 persons with Dementia Fees charged range from a minimum of £370 per week up-to a maximum of £658 per week. The home is located in a rural area with a public house and garden centre nearby. Public transport to this home is limited due to its location. The single storey property was initially purpose built and provides spacious communal rooms, single or shared bedrooms, some of which have en-suite facilities, plus an additional six bedrooms and a large lounge housed in the extension. The Home benefits from well-maintained gardens laid to lawn, with flowerbeds, patio and car parking to the front of the property. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. This inspection was carried out by one inspector and lasted seven hours. This is the third occasion we have inspected Hatton Court during the past 12 months. The main purpose of the inspection was to follow up progress made since the last inspection in September 2007, which resulted in the home having to provide us with a detailed plan of how systems in the home were to continue to improve. On this occasion we welcomed the services of an ‘Expert by Experience’ from the Help The Aged organisation to come along to help with the inspection. This person assisted in collecting information during the inspection to help make sure we focus on what matters to people who use this type of service. Shortly before the inspection, we the commission, contacted Hatton court and asked them to distribute satisfaction surveys to the people living in the home, their visitors and staff, on our behalf. This meant that although Hatton Court knew the inspection was imminent, they were not aware of the date or time the inspection would take place. A total of 2 residents, 6 relatives and 1 staff member returned written comments about the home to us. One person specifically asked to speak to us as a result of this survey. The inspection included observing activity within the home, inspecting the premises, an ‘in depth look’ at records for residents and staff, as well as observing, talking and listening to over half of the 51 people living there. Several of the staff on duty at the time of the inspection also shared their views about working at Hatton Court. Discussions with people were carried out in private, with people on their own, or together in groups in the lounges. Everyone including residents and staff was very welcoming and helpful throughout the inspection and were happy to share their comments, which are included in the main body of the report. A total of 24 out of a possible 38 National Minimum Standards for Older People were assessed on this occasion. Feedback about the conclusions of the inspection was given at the end of the inspection and upon the receipt of all the survey feedback. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Paperwork which accounts for the support care people receive continues to get better giving a improved overall view of the needs of the people living at Hatton Court. This confirms that the management team and staff group are committed to ensuring the service continues to improve. The home continues to improve the surroundings where the people live. Living conditions on the ‘Ellerdine Suite’ have been improved to the standard of the rest of the home. New carpets, sofas and armchairs make this part of the home more welcoming and a nicer place to live. The refurbishment of the dining room has been completed with the provision of new furniture. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 7 Management and administration systems continue to be developed in line with the policies of the company that owns the home. The home have devised new systems and paperwork to monitor staff performance and make sure all necessary day to day jobs are carried out. 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. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 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 Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 &3. Quality in this outcome area is good. People are provided with information they need to make an informed choice about whether the home can meet their needs. The assessment process ensures that the home has adequate information to judge whether the person’s needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Springcare, the Registered Providers for the service, have introduced a new corporate styled welcome pack for prospective residents, which contains information about the home including its ‘Statement of Purpose’ and ‘Service User Guide’. At the last inspection it was recommended that, Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 10 ‘The information the home provides to inform prospective residents they can meet their needs is further developed to include details about the services and accommodation provided for people with dementia related medical conditions’. This had not yet been addressed which means that anyone thinking about moving into the home is not aware that up to 14 people with dementia related conditions are generally cared for in a separate unit known as ‘The Ellerdine Suite’. An in depth look at the admission records of two people admitted to the home since the last inspection confirmed that satisfactory standards of recordkeeping have been maintained for this matter. Records showed that the home management had obtained enough information about both individuals to make sure they could offer them the care and support they needed in line with their personal tastes before a place was offered to them at Hatton Court. The paperwork also showed what written information residents and family were given to help them decide if Hatton Court would be a suitable choice for them. Information the home provided us with before the inspection led us to believe that people with dementia related conditions had a special assessment of their behavioural needs. The home stated on their improvement plan, ‘Assessments are now in place for all those with a dementia related condition using the ‘Basoll’ Assessment tool.’ However, examination of the records of the latest person admitted to the home with this condition confirmed this assessment had not been carried out. This home does not offer intermediate care. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 11 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&10 Quality in this outcome area is adequate. Staff are sensitive to the individual needs of each service user and meet these in a professional manner. Care plan records lack sufficient details to ensure that all residents’ needs are met. Medication is safely managed to make sure it promotes good health for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the of written comments received about the care carried out for the residents of Hatton Court care home were complimentary. One person commented, ‘The care provision is of a high standard. Dads appearance is always good – he always looks clean and fresh.’ Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 12 Another commented, ‘I formed the impression that efforts are being made in the home to cater for the individual needs and preferences of the residents, especially those who are able to express their needs and retain some independence.’ Staff members spoken to on the day of the inspection were most enthusiastic to demonstrate changes that had been brought about to improve care and support for the people in the home. The nurse in charge of the home commented that paperwork was improving all the time to make sure it covered all aspects of care. Requirements we made following the last inspection stated, • Care plans for people with dementia related conditions must be devised from an assessment tool specifically for this need, to properly account to show all their individual physical and behavioural needs are being met. and • Care plans for people living at Hatton Court must contain up to date risk assessments to ensure the safety and well being of a person is being addressed, and show details that all resident’s health care needs are met, as they should be. In response to meeting these requirements the information provided by the home before the inspection stated, ‘Care plans are in place to show that the health & personal care is based on the individual need. Risk assessments are now in place for all identified risks. All nurses now sign an accountability sheet to prove that the care plan is in place and has been evaluated accordingly.’ In order to check out the above comments, an in depth look at the records of five people living at the home who have a variety of support needs, was carried out. Care records confirmed most health needs are accounted for. • It was positive to see safety assessments had been carried out to make sure residents kept as much of their independence as possible, and that there was a lot more evidence of family involvement in the care plan paperwork for people with dementia related conditions. • Checks carried out by the home manager also showed that the pressure sores of 3 people who were admitted to the home with had completely healed in a very short space of time. However, not all care records gave an adequate ‘pen picture’ of all the care and support being carried out, especially for those people with dementia related conditions - several care plans lacked detail to keep individuals safe whilst promoting personal well being and independence. • Information identified in specialist assessment tools had not been considered in the care planning for people with behaviour challenges. The records of two people who had been involved in incidents as a result of such behaviours did not offer staff guidance how further incidents Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 13 could be avoided. Discussions with staff also confirmed they do not record any episodes of challenging behaviour in order to determine a reason for it. • Spot checks of two other peoples’ records were carried out upon observation of how staff assisted a resident who had fallen to the floor. Although their records had ‘moving and handling’ safety assessments completed, neither had details written down to advise staff how to safely transfer the individuals up from the floor in the event of a fall. Assessment of the home medication management systems showed the home staff follow satisfactory policies to make sure they are handled safely at all times. Recent improvements in medication administration paperwork clearly accounts for medicines that people living at the home prefer to manage themselves. A very knowledgeable nurse who was on duty during the inspection explained systems for the safe receipt, storage, administration and disposal of medications. The Controlled Drug records were examined and it appeared that all of the Controlled Drugs could be accounted for and that Controlled Drugs were being administered as prescribed. Examination of the Controlled Drug storage facilities were satisfactory, although staff were advised that alternative location for the storage of valuables also kept in that cupboard was needed. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 14 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 &15. Quality in this outcome area is good. The daily life and social activities arranged for people living at Hatton Court takes into account the differing expectations, preferences, lifestyle and capacities of each individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection visit many visitors were welcomed by various staff members in a professional friendly manner. Although the home is in a rural location, links with local community continue to be made. Residents confirmed that they have a new vicar who visits regularly. The local mobile library and ‘Rocky’ the ‘Pets as Therapy’ dog continue to visit the home. People were extremely complimentary about the positive impact the activity organiser has had on the lifestyle of the people in the home. Our ‘Expert by Experience’ spent a lot of her time in the company of this person and confirmed these comments. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 15 ‘People of varied abilities were involved in the morning communal activity of bingo using large playing cards. A person who was blind, was encouraged to participate and feel the cards to find the appropriate one. The activity coordinator also provides one-to-one stimulation and activity to individual residents who cannot, or who prefer not to join in with the communal activities.’ Observations and discussions with staff on duty confirmed they were knowledgeable about people’s dietary needs, and the best way to serve their residents’ food so they can dine independently. Residents were served courteously and with patience by the carers. Although the home has vacancies to fill within its catering team, this does not have appeared to affect the quality of meals provided. All residents who made comments about the meal provision were in agreement that the food was good, and they always had plenty of choice of alternative options if they did not fancy the main meal of the day. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 16 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 &18 Quality in this outcome area is good. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence All comments received from people living, visiting and working at the home were unanimous in that people knew what to do if they had to make a complaint. One relative commented, ‘I have had no major problems that have needed to be dealt with. Minor problems have always been dealt with appropriately and efficiently’. Springcare, the company who owns Hatton Court actively welcomes comments in order to improve the service they provide. The home complaints procedure on display in the entrance area to the home clearly describes what people have to do if they are not happy with the service at Hatton Court. This information is also contained in the Springcare resident ‘welcome information folder’ mentioned earlier. The home has fully implemented the company monitoring Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 17 systems for this matter and a company area manager checks these at least monthly. We have not received any complaints about this service since the last inspection in September 2007.The records of a complaint the home itself received since then reflected that it had been dealt with in a prompt and professional manner. Management improvements have continued to make sure people feel comfortable to raise any concerns they are unhappy about. Up to date policies and procedures for safeguarding adults are freely available at Hatton Court for all staff to refer to. Comments received from visiting professionals as well as examination of staff records confirmed that all new recruits to the staff team have received safeguarding adults training as part of their introduction to working at the home. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. The physical design and layout of the home enables the majority of the people who use the service to live in a well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When comments were asked about what the home does well, several people remarked on how clean the home was. One person stated, ‘The home’s cleanliness is of a high standard – always clean fresh and tidy’ Findings on the tour of the home confirmed the cosmetic appearance of the communal areas, especially in the ‘Ellerdine Suite’ were much improved. The provision of new carpeting soft furnishings and seating has made this area as welcoming and comfortable as other parts of the home. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 19 New furniture has also been provided for the dining room. Some residents commented the new chairs were not as comfortable as the old ones, whereas others felt they were ‘as good as you would find anywhere’. The resident smoking facilities have also been further improved, and no longer challenge the welcoming atmosphere as you enter the home. Residents also told us about the shop that has recently opened being a useful addition to the facilities of Hatton court. One of our main concerns at the last inspection was that the bathrooms and toilet facilities were especially showing signs of wear and tear, and that the 14 people living on the Ellerdine Suite only had one fully operational bathroom. During this inspection it was noted that three bathrooms were out of order. The hot water temperature records for one located in the main part of the home had not been completed since the beginning of December 2007 confirming resident and staff comments that it had been out of use for some time. It was good to see new shower equipment was seen on The Ellerdine Suite awaiting installation, as the flooring of the only bathroom people can use has deteriorated further and poses a hygiene and trip hazard. Cleanliness of equipment such as bath seats was also an issue at the last inspection, and once more, bath seats were visibly stained. In response to requirements we made about the maintenance and upkeep of the home following the last inspection in September The home management commented in their improvement plan, ‘New cleaning schedules are being developed to ensure that all parts of the home are cleaned regularly, this includes the cleaning of bath seats and other equipment. Cleaning schedules will be checked and signed weekly by the Manager.’ Flooring will be repaired when refurbishment of this bathroom is carried out later this year. The redecoration / refurbishment plan was sent to CSCI on 19/11/07.’ • When the cleaning schedules were checked it was seen they did not list communal equipment such as bath seats, the residents fridge on the Ellerdine Suite or hoisting equipment. On the inspection day this equipment was visibly soiled in need of cleaning. The refurbishment plan Hatton Court sent to us does not identify bathroom flooring to be replaced, although it did identify the new shower was to be installed by the beginning of December 2007. • Infection control practices have been enhanced by the provision of footoperated bins. However hand washing facilities in some parts of the home are in need of improvement as some hand wash areas lacked necessary equipment for this job. In addition, the lack of hot water supply to the staff toilet was reported to be in the process of being addressed. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 20 The above findings show progress with improving these areas has been slower than expected by us and as planned by the company who owns the home. The home had an infection control audit by the Primary Care Trust at the end of January this year. The report for the visit arrived on the inspection day and reflected similar findings mentioned in this report. The home has also been inspected by the environmental health department, at the beginning of February. So far they are making good progress in carrying out the 11 actions that were recommended as a result of this visit. It is recommended the home management devise an action plan in response to these reports in order to further improve standards and day to day working practices for these matters. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 21 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 & 30. Quality in this outcome area is adequate. Staff in the home are being trained and are in sufficient numbers to fill the aims of the home and meet the changing needs of residents. People living at the home are supported and protected by the homes recruitment policy and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence Comments received from residents and relatives about staff were in the main complimentary, although the continued use of agency staff has resulted in comments that people are being looked after by staff that are not fully aware of their needs. People commented, ‘Staff are all very pleasant and caring .My relative’s communication is limited but they are patient and try hard to meet his wishes.’ ‘Regular staff provide the care very well’ ‘ Some new staff and agency staff don’t know my father so well don’t meet his needs which can lead to upset and problems’ Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 22 As a result of in depth discussions with several residents and staff we were able to form the impression that the nurse and the carers on duty were all quite stretched, although evidently coping. Rotas examined for the fortnight before and after the inspection confirmed the home is adequately staffed with the appropriate skills of nurses and carers to meet the needs of residents. The home continues to complete a separate allocation sheet for the ‘Ellerdine Suite’, so that staff are fully aware who is working in that specific part of the home. During the week of the inspection ten shifts had been covered by agency staff on day and night duty. This is expected to increase as two trained nurses were reported to be leaving employment at the home in the near future. Springcare the company are very aware of this issue and acknowledged the challenges of recruitment and retention of staff at the home being a major factor in standards not been as good as they would have liked. Examination of the records of two new starters since the last inspection demonstrated a thorough recruitment and vetting process for this matter. Files were seen to be well organised and were a credit to the administrator who manages this paperwork. Excellent record keeping shows how new starters have been looked after by experienced staff members to help them settle in their role. The ‘at a glance’ training tracker form which has been kept up to date and shows progress the staff team have made with their training and development. Review of four sets of staff records confirmed that training certificates seen in their files matched the training recorded in the training tracker tool. All records showed people have received necessary training to carry out their job including medication management. However none of the files looked at or the training tracker identified that staff had been trained in bedrail safety. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 23 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, 36 & 38. Quality in this outcome area is adequate. The management team is committed to improving the quality of the service. Some systems for the health, safety and welfare for residents, staff and visitors need to be improved and adjusted to make sure that they are kept up to date, to meet people’s changing needs and safeguard their well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Christine Simcock, the Registered Manager, continues to show her ongoing commitment to be a competent home manager. Although she was not Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 24 available at the time of the inspection, information and comments received confirmed that she directs and motivates her team in a positive way on a daily basis. One relative who visits the home very regularly wrote, ‘Generally the home runs very smoothly and efficiently.’ A resident also commented, ‘I find the home manager to be very helpful and friendly – she is always willing to listen and help’ A permanent deputy manager has also been appointed to support Mrs Simcock in her role and was due to commence working at Hatton Court the day after the inspection. It is positive the home has had the support and guidance of two Springcare Area Managers who carry out monthly quality audits to monitor the progress the home is making to meeting National Minimum Standards for Older People. Since the last inspection they have devised a system to monitor the effectiveness of the ‘Improvement Plan’ they produced for us. Although this could not be fully explored without the presence of the manager, some of the issues recorded earlier in the report indicate this system requires further expansion to monitor all actions the plan describes. The management team continue to be acting upon some of the comments people made as a result of the home’s annual satisfaction survey, including the provision of ramps so people can access the gardens and car park. This shows the home aims to being run for the best interests of the people who live there. A revised method of the way the home manages all monies and valuables held in safekeeping for its residents now assures us that this aspect of resident well being is safeguarded. However a safe storage facility for valuables is required for staff to access on a daily basis to make sure the controlled drug cupboard is not used for this purpose. Review of the paperwork and records for the regular maintenance of equipment such as lifts and hoists show this to be all in order for the majority of equipment in use, although bedrail safety continues to be a challenge at Hatton Court. Findings were similar to the last inspection which resulted in an ‘Immediate Requirement’ for the home to devise a system to make sure all bedrails are safely installed, and to provide appropriate paperwork to confirm that residents are protected from avoidable risks to their health and safety. Even though staff keep daily records of checks carried out on bedrails to confirm they are correctly installed, spot checks of two bedrail installations confirmed they were fitted in an unsafe manner, and were not fitted in accordance with the relevant health and safety legislation. In addition, the bedrail safety records for both people had not been kept up to date. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 25 The home maintenance man was on site and carried out further safety checks, which resulted in a total of 5 sets of bedrails having to be made secure. These findings clearly show there has been inadequate training for staff for this matter and the home needs to further improve this important aspect of health and safety in the home. These findings demonstrates the home does not have a robust systems in place to maximise the safety of people living in the home, and that the home have failed to act appropriately in response to urgent actions we identified. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 1 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 1 Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 27 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 OP21 Regulation 23 (2)(j) Requirement Timescale for action 26/05/08 2 OP38 23 (2) (c) People who use the service must be provided with clean adequate bathing facilities at all times in all parts of the home they have access to, to make sure hygiene needs can be met Competent individuals must 26/02/08 assess bedrails in use within the home for the risk they present to the people who use the service, to ensure they are correctly installed. Any actions taken to minimise risk must be carried out and monitored by appropriately trained personnel in accordance with the relevant Medical Hazard Reporting Agency and Health and Safety Executive Guidance for this equipment. Immediate Requirement 19/09/07. Previous timescales of 21/09/07 not met. Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations It is recommended the information the home provides to inform prospective residents they can meet their needs is further developed to include details about the services and accommodation provided for people with dementia related medical conditions. Care plans for people with dementia related conditions must be devised from an assessment tool specifically for this need, to properly account to show all their individual physical and behavioural needs are being met on a day to day basis. Care plans for people living at Hatton Court must contain up to date risk assessments to ensure the safety and well being of a person is being addressed, and show details that all resident’s health care needs are being planned and met, as they should be. It is recommended the home cleaning schedules are further expanded in line with the Hatton court Improvement Plan at the earliest convenience to make sure there are consistent standards of cleanliness of equipment used daily in the home. It is recommended that adequate hand washing facilities must be provided, especially in high risk areas such as in staff toilets It is recommended the home compile a time bound action plan in order to respond to the advice and recommendations made by the Environmental Health Department and Primary Care Trust. It is recommended that staff training records are accurately maintained to clarify all training they have received including topics such as bedrail safety to ensure staff can fulfil the aims of the home and meet changing needs of the people living there. It is recommended that alternative secure storage for valuables is provided for staff to access on a 24 hour /seven day basis in order for the home to fully comply with medication legislation for the storage of Controlled Drugs. DS0000064716.V356498.R01.S.doc Version 5.2 Page 29 2 OP7 3 OP7 4 OP26 5 6 OP26 OP26 7 OP30 8 OP35 Hatton Court Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Hatton Court DS0000064716.V356498.R01.S.doc Version 5.2 Page 30 - 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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