Inspection on 12/04/05 for Hawksyard Priory Care Home

This inspection was carried out on 12th April 2005.

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

Hawksyard Priory Care Home 05/08/08

Hawksyard Priory Care Home 05/09/06

Hawksyard Priory Care Home 04/10/05

Hawksyard Priory Care Home 05/10/04

Hawksyard Priory Care Home 16/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hawksyard Priory Armitage Lane Armitage Rugeley Staffordshire WS15 1PT Lead Inspector David Cowser Unannounced 12 April 2005 09.00 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. Hawksyard Priory Version 1.10 Page 3 SERVICE INFORMATION Name of service Hawksyard Priory Address Armitage Lane Armitage Rugeley Staffordshire WS15 1PT 01543 490012 01543 492546 matron@hawksyardpriory.co.uk Hawksyard Priory Nursing Home Ltd 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) Mrs Susan Haskett Care Home with Nursing 76 DE(E) LD MD(E) PD PD(E) TI Category(ies) of 27 registration, with number 1 of places 27 6 49 4 Hawksyard Priory Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 PD(E) Minimum age 60 years 2 DE(E) - MD(E) Minimum age 60 years 3 Conditions for Palliative Care That at least one of the Nursing Staff have the recognised Qualification ENB931 or K260. Date of last inspection 05/10/04 Brief Description of the Service: Hawkesyard Priory is a privately owned care home situated on the outskirts of the Staffordshire village of Armitage. The home is a former Dominican Priory and is set in large grounds. The home is registered to provide both nursing and personal care, including mental health care, for up to a total of 74 elderly service users. Access to the home is via a long driveway. A regular bus service stops at the end of the drive and all shops and community facilities are available in the village. Accommodation is provided on three floors. The ground floor (22 beds) and second floor (26 beds) offer accommodation for service users with general personal care and nursing care needs. The top floor (26 beds) offers accommodation for service users with mental healthcare needs. Separate lounge and dining facilities are provided on each floor. Hairdressing and smoking facilities are also provided. A large church and a library are part of the buildings. Services and facilities including laundry, catering and hotel services facilities are good. Activities, hobbies and entertainment all take place and transport is provided when required. Families and friends are encouraged to take part in activities and trips out. Qualified nurses and teams of care assistants provide care. Community nurses and NHS facilities are accessed when required. A local GP practice and Pharmacy service the home. Hawksyard Priory Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced visit was made on the 12 April 2005 at 09.00hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 7hrs. The registered care manager, who is a first level nurse and a joint owner, was in charge of the home accompanied by two more registered nurses and fourteen care assistants. Ancillary staff on duty included; cook and 2 catering assistants, housekeeper, 7 domestic staff, laundry worker, 4 maintenance/gardeners, and a business support worker. These staffing levels were adequate to meet the needs of current 69 residents in the home. The total of 69 elderly residents included; 61 receiving nursing care (37 having needs associated with physical disablement 24 having needs associated with a mental disorder or dementia related condition), and 8 people receiving personal care for needs associate with old age. The inspection included the following elements; a tour of the building, inspection of records relating to provision of care, discussions with several residents and relatives and also staff members, observation and sampling of other services provided such as catering and laundry, an inspection of the managerial aspects such as staffing, quality assurance and health & safety. Since the last inspection on 5 October 2004; there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. It was evident that aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. No complaints, incidents or reports of abuse of any kind had been received since the last inspection and policies and procedures seen covered these issues. The home was fit for purpose, well maintained, and provided a safe environment for the registered client groups. A homely atmosphere had been created, and the premised were clean warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including Hawksyard Priory Version 1.10 Page 6 catering and laundry were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received supervision. The home appeared to be managed well by a qualified and competent care manager at the helm. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures are adopted. No requirements or recommendations, against the regulations or the minimum standards, had been made in the last inspection report and none were made during this inspection. What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were made as a result of this inspection. It is understood that plans are currently being drawn up and submitted for alterations and extensions to the home that will provide more single bedroom accommodation. Currently 24 beds out of the total 76 beds (37 ) are in single bedrooms. Hawksyard Priory Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hawksyard Priory Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Hawksyard Priory Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Information had been available for prospective service users, and they had been enabled to make an informed choice about staying in the home. Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. EVIDENCE: The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. A service user guide was seen in use, along with the comprehensive statement of purpose. All involved had the opportunity to visit the home prior to choosing to stay. Two residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within their care plans. Contracts had been agreed and signed by residents/representatives. Hawksyard Priory Version 1.10 Page 10 The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents and relatives asked confirmed that they had been fully involved and in agreement with the assessments. The records seen and a discussion with the staff evidenced that nursing and care staff, individually and collectively, had the necessary experience and qualifications to meet the assessed needs of the current service users. Hawksyard Priory Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The assessed health and personal care needs of residents had been well documented and were being met, with good standards of care. There was a safe system for the receipt, storage, administration and disposal of medicines. Residents were treated with respect, and privacy and dignity were afforded to them, during the caring process. EVIDENCE: The service users and their relatives spoken to all commented positively about the care being provided, and one family highlighted how their mothers’ health and well being had improved greatly since entering the home. The service user plans and associated documentation was well written, meaningful and reflected the current condition of residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being well met. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A local GP practice and a local Hawksyard Priory Version 1.10 Page 12 pharmacist service the home, and there is a good working relationship with them. Records of their visits were seen. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only trained nurses administered medicines and that no resident was ‘self medicating’. Hawksyard Priory Version 1.10 Page 13 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) 12,13,14,15 Residents were satisfied with their lifestyle in the home, and they were able to exercise choice and influence decisions affecting them. Contact had been maintained with relatives and friends of residents, and opportunities to access the local community had been made available. Catering aspects were good with balanced nutritious meals being served, along with resident consultation and choice. EVIDENCE: All residents spoken to told the inspector that they were happy with their stay in the home, and that the staff were very good to them. They said that their views were listened to and that they had been able to influence decisions made by the manager. A check on the records and a discussion with six residents, four relatives and several staff evidenced that activities, entertainment and trips out, had been well arranged and enjoyed by residents. The two activities organisers employed by the home went through their records with the inspector and told of the varied activities and links with the community that had taken place. Visitors to the home, when asked, said that they were always made welcome and that communication with the management of the home was very good. The residents and visitors spoken to evidence that that they had been able to Hawksyard Priory Version 1.10 Page 14 influence decisions concerning the running and organisation of the home, and this was seen documented. The minutes of residents meetings were seen documented. Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met, particularly with the very poorly nursing patients with specific needs of nutritional intake. The cook when asked said that there were no financial restrictions placed and that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. Hawksyard Priory Version 1.10 Page 15 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) 16.18 Complaints or grumbles are listened to and resolved. The home policies, procedures and staff training, protected residents from aspects of abuse. EVIDENCE: An examination of the complaints book and the policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection no complaints had been recorded or brought to the attention of this commission. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Hawksyard Priory Version 1.10 Page 16 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) 19,26 The home provides a safe and well-maintained environment for residents. The home was clean, warm and tidy. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The duty rosters evidenced that adequate ancillary staff were employed. The domestic staff told the inspector of their knowledge on infection control, and showed him the policy documentation and also schedules that they worked to. Adequate hand washing facilities were available throughout the home. A sluice machine has recently been installed within a dirty utility room. The maintenance supervisor went through the maintenance records and referred to the recent upgrading of the hot water supplies, and other maintenance work that was taking place. The records evidence that maintenance of the premises was being given a high priority. On going painting and re-decorating was seen being done. Hawksyard Priory Version 1.10 Page 17 There are no outstanding issues known from the Fire Prevention or Environmental health departments. Hawksyard Priory Version 1.10 Page 18 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) 27,28,29,30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment procedures had been correctly addressed which had contributed to the protection of service users. EVIDENCE: The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. The following care staff had been on duty or exceeded for the 69 residents; a.m. 2RGN/RMN 14 Care assistants ( Care manager RGN for 5 days), p.m. 2RGN/RMN 11 Care assistants, nights 2RGN/RMN 6 Care assistants. In addition to the above adequate ancillary staff had been rostered on duty throughout the week. Six residents asked stated that staff were available when requested, and that the staff were capable. In addition to first level nurses the home had 50 of care assistants trained to NVQ level 2 or above. Hawksyard Priory Version 1.10 Page 19 The home recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had been given a high priority and the training records of individuals were seen. Hawksyard Priory Version 1.10 Page 20 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) 33,35,38 The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. EVIDENCE: From observations made, discussion with service users, the manager and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and most residents and families had chosen to do so. For Hawksyard Priory Version 1.10 Page 21 the residents that had requested the home to administer finances on their behalf records had been completed and were seen correct, with a safe system in place. Day to day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examinations of plant and equipment was all correct and up to date. The manager and maintenance staff spoken to confirmed that health and safety issues are given a high priority. Hawksyard Priory Version 1.10 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 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 Standard No 16 17 18 Score 4 x 3 x x 3 x 3 x x 3 Hawksyard Priory Version 1.10 Page 23 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 Regulation None 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. Refer to Standard None Good Practice Recommendations Hawksyard Priory Version 1.10 Page 24 Commission for Social Care Inspection Stafford Office - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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