Inspection on 09/01/06 for Hayes Cottage

This inspection was carried out on 9th January 2006.

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

Hayes Cottage 16/07/07

Hayes Cottage 04/09/06

Hayes Cottage 22/08/05

Hayes Cottage 24/02/05

Hayes Cottage 02/08/04

Hayes Cottage 15/01/04

Hayes Cottage 05/08/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hayes Cottage Grange Road Hayes Middlesex UB3 2RR Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 10:15 9 & 17 January 2006 th th 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 Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hayes Cottage Address Grange Road Hayes Middlesex UB3 2RR 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) 020 8573 2052 020 8573 5593 HAYES COTTAGE NURSING HOME Limited Ms Ani Grace Manayin Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Six of the beds currently registered may be used as Palliative Care Beds as agreed by the Commission for Social Care Inspection, on 1st August 2005. 22nd August 2005 Date of last inspection Brief Description of the Service: Hayes Cottage Nursing Home was previously the Hayes Cottage Hospital. The building has been developed and extended to its present condition. The home provides accommodation for 54 service users who require nursing care. The home has a contract with Hillingdon Social Services for 12 respite care beds, six of which can be used to provide palliative care, and these are included within the total of 54 beds. There are 44 single rooms, 13 with en suite facilities, and 5 double rooms, one with en suite facilities. There are several sitting areas to include a conservatory, plus a main dining room. The garden is well maintained and has chairs, tables and parasols for the use of service users and their visitors. The home is situated in a residential area of Hayes. It is well maintained and has a good atmosphere. The Beck Theatre is within walking distance from the home. There are shops and local amenities plus Hillingdon Hospital close to the home. The home has a social activities policy, which lists many ideas for social activities throughout the year and also ideas for diversional therapy on a day-to-day basis. 36 service users were accommodated at the home on the day of inspection. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 11 hours was spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff records, financial records, maintenance and servicing records. 10 service users, 6 staff and 3 visitors were spoken with as part of the inspection process. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 6 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 Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Written agreements are available for service users, providing clear information about the services provided. Service users are assessed prior to admission to ensure the home can meet their needs. Service users and their representatives are encouraged to visit prior to admission to see if it is appropriate for their needs. Staff have received training and have experience to ensure that they are able to meet any specialist care needs of the service users. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, both of which had been updated since the last inspection. Copies of the Service User Guide are available in the service users rooms. Copies of both documents are also kept in the library. The home also has a new brochure, which has been tastefully compiled and provides good information about the services offered by the home. The home has individual terms and conditions and contracts for privately funded service users. There is a block contract with the Primary Care Trust Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 8 (PCT) for palliative care and respite care beds, and service users receive copies of the homes’ terms and conditions. All prospective service users are assessed prior to admission to ensure the home can meet their needs. Copies of Social Services and/or PCT assessments are also obtained. For service users for palliative care, a letter from the palliative care Consultant is also obtained. In addition to providing nursing care for elderly service users, the home is also registered to provide palliative care for up to 6 service users. There is evidence that staff have received training to ensure they have the knowledge to meet the specialist care needs of these service users. The Registered Manager said that prospective service users and their representatives are encouraged to visit the home prior to admission, to ascertain if it meets their needs and is appropriate for them. The Registered Manager meets prospective service users at the time of the pre-admission assessment also. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The service user plans are generally well formulated and updates take place, thus ensuring that the information required by staff to meet the service users needs is clear and up to date. Shortfalls identified should be easy to address. Medications are generally well managed in the home, however shortfalls identified could potentially place service users at risk. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy and dignity. Service users wishes and needs in respect of death and dying are being met, thus ensuring that the service users final days are comfortable and appropriately managed. EVIDENCE: Five service user plans were sampled as part of the inspection process. Generally these were up to date and had been reviewed monthly. There was evidence of new service user plans being formulated for newly identified needs. Risk assessments for falls were in place. One service user plan viewed was for a service user recently admitted to the home, and this already gave a good overall picture of the service users needs, with some documentation to be completed. There was evidence of service user and/or representative involvement in the service user plans, and relatives spoken with confirmed this involvement. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 10 For service users with wounds, individual care plans had been formulated for each wound identified, and the progress of each wound was clearly recorded. Pressure relieving equipment was seen in use in the home, and the specific equipment in use for each service user was identified in the service user plan. There was evidence of input from healthcare professionals to include the Tissue Viability Nurse Specialist. Assessments for pressure sore risk, nutrition and moving & handling were in place. The specific moving & handling equipment for each service user had been recorded in the service user plans. Continence assessments had not always been completed, and care plans for some continence care needs were not always in place. This was discussed and the Registered Manager said that a template for such a care plan would be formulated. Written consents for the use of bedrails were available, but full assessments for the appropriateness of their use had not been completed. On the first day of inspection the Inspector viewed samples of the medication records and management processes. The CSCI Pharmacist Inspector carried out a full medications inspection on 17th January 2006 and a separate inspection report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for Medication Administration Record. Staff were heard to speak with service users in a courteous manner. Service users who spoke with the Inspector said that the staff are very caring and work hard to meet their needs. Visitors said that they are made welcome at the home, and the staff had a caring, open attitude with service users and their representatives. Bedrooms viewed were personalised and service users are encouraged to bring in personal possessions, in line with health & safety. The home is registered to provide palliative care for 6 service users. A palliative care procedure is now in place. Staff working on the palliative care unit had undergone appropriate training to ensure they have the skills and knowledge to meet the service users needs. This standard was covered in more depth at the last inspection. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meal provision is good, offering choice and catering for special dietary needs. EVIDENCE: Service users were observed enjoying the lunchtime meal and staff were seen to be assisting service users in an gentle manner. The Inspector sampled the meal and it was well presented and tasty. Service users spoken with were overall satisfied with the food provision and choice at the home. The kitchen was clean and tidy and cleaning schedules were up to date. Service users have a choice of meals and these choices are recorded. The kitchen staff are made aware of any service user who require a special diet for religious or medical reasons. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were all viewed and met at the last inspection. The Registered Manager reported no complaints had been received since the last inspection and that there had been no adult protection issues. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the environment within this home is good, providing service users with a homely place to live. The home was clean and systems for the prevention of the spread of infection were being adhered to, thus safeguarding service users. EVIDENCE: During the tour of the home all areas viewed were in a good state of décor, and several of the bedrooms were very personalised. The maintenance man maintains a list of rooms and areas within the home that have been redecorated, with timescales of completion. The records also identify the paint used in each area for ease of future reference. The Registered Manager carries out a monthly audit of the home and there is an ongoing record of any repairs required. The home was clean and smelled fresh throughout. The laundry room was clean and tidy and the home has clear infection control policies and procedures in place. There have been no changes in the laundry management since the last inspection. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home is appropriately staffed to meet the current needs of the service users. Training to include induction, foundation and NVQ in care are in place to provide staff with the skills and knowledge to care for the service users. Staff recruitment is generally robust, but shortfalls could potentially place service users at risk. EVIDENCE: At the time of inspection the home was appropriately staffed to meet the needs of the service users. The palliative care unit is staffed separately. The home had 36 service users and the staffing had been adjusted accordingly. The Registered Manager is very aware of the need to maintain adequate staffing and management hours to ensure the continuing smooth running of the home. Staff spoken with said that the teamwork was good within the home and there was a good atmosphere throughout. The home has a general induction programme for all staff to be familiarised with the work environment, protocols, policies and procedures. There are also induction and foundation training programmes to meet the Skills for Care (formerly TOPSS) core standards. The Registered Manager reported that the majority of the care staff had undergone NVQ in care training, to level 2 or above. The training records demonstrated a good calendar of training events, to include palliative care training and other topics relevant to the service user group needs. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 15 The Inspector viewed three sets of staff employment records. A central list of Criminal Records Bureau check information is maintained. Application forms, health questionnaires, contracts and terms & conditions were available. 2 references had been obtained, but in one instance it was not clear if these included the previous employer. In two instances gaps in the employment history were noted, and no explanations for these omissions had been given. The need to ensure a full employment history is obtained was discussed. Photographs were not seen on two files viewed. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38 Systems are in place for the ongoing auditing of the home, for quality assurance monitoring and progress. Service users finances are well managed and thus safeguarded. Staff supervision is in place thus promoting a forum for discussion and professional development. The home is well maintained, thus providing a safe environment for service users. Some staff had not completed all health & safety training updates, which could pose a risk to service users and staff. EVIDENCE: The home has a quality assurance programme in place. There was evidence of regular audits taking place for areas of care, maintenance and home management. The Registered Manager reported that the Responsible Individual had recently carried out a Regulation 26 inspection for the home, with the report to be forwarded to the CSCI. Service user and representative satisfaction surveys are carried out and the results are collated and a copy forwarded to the CSCI. Service users and representatives spoken with said Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 17 that they are kept up to date with events in the home and there is good communication between service users, representatives and the home management and staff teams. Policies are in place for the management of service users personal monies. Clear income and expenditure records are maintained for any service users for whom personal monies are held, and there was evidence of regular auditing of these records. Receipts of expenditure are kept. The home has a safe facility. The Registered Manager reported that supervision for all staff providing care is carried out, and the systems for delivering this supervision have been discussed at staff meetings. The registered nurses carry out the supervision for the care staff. The Inspector recommended a matrix to evidence the dates of supervision for each member of staff be formulated, to provide ‘at a glance’ information. The Inspector sampled servicing and maintenance records, and all those viewed were up to date. The maintenance man maintains clear records to show the frequency of all in-house servicing and maintenance carried out, as well as the servicing of equipment carried out by external contractors. The records for the hot water temperature checks showed that one safety mixer valve had been out of order for several months, and the water temperature was showing at 22º centigrade. The importance of ensuring all safety mixer valves are maintained in good working order to provide hot water to service users at near to 43º centigrade was discussed and correspondence has since been received by the CSCI stating that the valve has been replaced. Risk assessments for laundry equipment, bedrooms and safe working practices were in place. Those for kitchen equipment were not available at the time of the inspection. COSHH information to include safety data sheets for each product used was in place. The fire risk assessment was last updated 20/01/05 and was due to be reviewed. Mandatory training had been recorded as having taken place for most staff, and the Registered Manager said that she would follow up any gaps noted. The matrix for staff training was clear and easy to follow. Fire drills had not always been recorded as having taken place at the required intervals, those being 6 monthly for all day staff and 3 monthly for all night staff, and the need to address this was discussed. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 18 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 2 Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 19 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 OP8 Regulation 17(1)(a) Requirement Assessments to include those for continence must be completed for each service user. (previous timescale of 01/10/05 not met) Care plans must be formulated for each identified need, to include all continence care needs. Bedrail assessments must clearly identify the reason for and appropriateness of the use of bedrails for each individual. (previous timescale of 02/09/05 not met) Staff must be reminded that the MAR must be endorsed accurately after medicines are administered. Medicines must be administered as prescribed. Instructions for oxygen must be given by the GP either on the MAR or in a separate protocol. Staff must thoroughly check the MAR each cycle for accuracy when receiving medication. The service user allergic to penicillin should be assessed by the GP and the risk assessment DS0000010933.V275318.R01.S.doc Timescale for action 01/02/06 2. OP8 17(1)(a) 10/02/06 3. OP8 13(4)&(7) 01/02/06 4. OP9 13(2) 01/02/06 5. 6. 7. OP9 OP9 OP9 13(2) 13(2) 13(2) 01/03/06 01/02/06 01/03/06 Hayes Cottage Version 5.1 Page 20 8. 9. 10 OP9 OP9 OP29 13(2) 13(2) 17 11. OP38 18 12. 13. OP38 OP38 13(4) 13(4) amended as appropriate. Controlled drugs must be stored and recorded correctly. The home must use finger pricking devices or lancets for professional use. Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. All staff must undergo fire drill training at intervals of a minimum of 6 monthly for all day staff and 3 monthly for all night staff. An action plan to address this must be drawn up. Risk assessments for kitchen equipment must be available for inspection. Any repairs identified must be assessed and promptly addressed. 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 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. 3. 4. Refer to Standard OP9 OP9 OP9 OP36 Good Practice Recommendations The pharmacist should be requested to update the MAR to remove discontinued items and to avoid duplication and to ensure that all current medication is listed. The pharmacist should be requested to supply the blisters in the same order as the MAR. That the home purchases a larger Controlled drugs cupboard for the first floor. It is strongly recommended that as required CD balances be checked daily. A matrix to evidence the dates of supervision carried out with each member of staff should be available. Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hayes Cottage DS0000010933.V275318.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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