Inspection on 29/06/06 for Hayes Court

This inspection was carried out on 29th June 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 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

Hayes Court 08/04/08

Hayes Court 29/05/07

Hayes Court 22/02/06

Hayes Court 18/07/05

Hayes Court 14/01/05

Hayes Court 19/07/04

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 Court Hayes Court Nursing Home 50 Hayes Lane Kenley Surrey CR8 5LA Lead Inspector Mohammad Peerbux Key Unannounced Inspection 29th June 2006 9:00am 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 Court DS0000019027.V301362.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. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayes Court Address Hayes Court Nursing Home 50 Hayes Lane Kenley Surrey CR8 5LA 020 8660 3432 020 8668 4522 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) www.hayescourt.com Dr Michael John Sturgess *** Post Vacant *** Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user under the age of 65 to be accommodated for two weeks respite care. 22nd February 2006 Date of last inspection Brief Description of the Service: Hayes Court is a 56-bedded care home. It provides both nursing and residential care. The home is set in its own quite substantial grounds about a mile from Kenley railway station. Access for wheelchair users is available. There are three floors with access by stairs or a small passenger lift. The home provides the possibility a double room on each floor, though only one can be occupied doubly at any one time to keep within the registered number. The remaining bedrooms are all single occupancy; all bedrooms have en-suite facilities. The majority of rooms are located on the ground floor, with a small number in the original main building on first and second floors. There are a number of communal areas located throughout the home, and a conservatory for the use of service users. Parts of the garden are also accessible to them. Visitors may be seen in private in users rooms, or in one of the small lounges. The range of weekly fees is between £352 and £750. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2006/07. It was an unannounced inspection and took place over six hours. Some times were spent looking at the policies and procedures, talking to the Registered Provider, staff and to some of the service users. They are all thanked for their time and assistance. A tour of the building was also carried out. Some of the service users spoken to stated that they were happy with the care being provided. An immediate requirement was issued on the day of the inspection with regards to the administration of medication. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? There were no requirement or recommendation from the last inspection. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Statement of Purpose, and Service User’s Guide provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. Overall the home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: The home has a comprehensive Statement of Purpose, and Service User’s Guide, a copy of which is issued to each service user. Both are extremely well presented and cover all the information required by the Care Homes Regulations (2001), including the aims and objectives of the home and the facilities and services provided. However it is recommended that the service user’s guide be made available in formats suitable for the service users for Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 9 whom the home is intended (e.g. appropriate languages, pictures, video, audio or explanation). Assessments and care plans looked at indicated that the home has the capacity to meet the assessed needs of service users presenting varying degrees of cognitive and physical dependency. Intermediate care for rehabilitation and return to the community is not provided by this home. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. However the system for administration of medication is poor and potentially place service users at risk. EVIDENCE: A sample of service user’s care plans were examined and it was evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. There was also evidence that service users’ care needs are being regularly reviewed with amendments being made to the service user plans where needs have changed. Service users expressed their satisfaction with the help provided by care staff, and felt that their care needs are being well met. The staff on duty was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 11 The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The registered person must ensure that the administration/nonadministration of all medication is recorded accurately. It was also noted that a number of service users did not have their allergies written on their MAR sheets, this potentially places them at risk. The registered person must ensure that the allergy section on the medication profiles is complete for all service users. Some items of medication were labelled “use as directed”. No other directions were seen for administration. The registered person must ensure that clear directions for administration are in place for all items of medication. One service user is able to self-medicate and no risk assessment was in place. The registered person is required to carry out a risk assessment on service users who self-medicate. It was also noted that three items of medication were out of date. The registered person must ensure that items of medication that are out of date are disposed of as soon as possible. Failure could results to serious repercussions to the health and welfare of service users. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. The registered provider informed that staff respect service users wishes regarding daily routines. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. The registered provider stated that visitors are welcome at the home at any time however they have to phone if they are coming after 8pm as the doors are locked after that time. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 13 It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: Adequate procedures are in place for dealing with complaints. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. A copy of Croydon Council vulnerable adult protection procedures was available in the home. The registered provider assured that there have been no allegations of abuse made within the home since the last inspection. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home is situated in substantial grounds, some parts of which are accessible to users. The surrounding terrain is hilly - and therefore difficult for people with limited mobility. The home provides a satisfactory amount of communal space. There is also a very pleasant, well-furnished, conservatory. The bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 16 The home is clean, hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However staff training needs to be addressed as this could have an impact on the standards of care being provided. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. Six carers currently hold an NVQ level 2 qualification. The management team are aware that they will have to give consideration as to how this standard will be achieved. The registered provider must ensure that 50 per cent of the care staff must have a NVQ 2 qualification within the allocated time. As part of the inspection process four staff personnel files were sampled for references, criminal record checks, application forms and copies of identification. They contained all the relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001.However it was noted that three staff started working in the home with just POVA First clearance only while they were still waiting for their CRB checks to come back. It is seen by the Commission to be poor recruitment practice for employers to start new staff on POVA clearance only. POVA First is only to be used when there is a critical risk Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 18 to the health and welfare the service user. A number of conditions need to be in place if a new staff starts work with POVA clearance only. • The employer must write to the Commission For Social Care Inspection requesting and have agreement that a new staff starts work at the home with POVA clearance only. The home must explain the critical risk to the service user/s. The employer must provide evidence that all other documentation as stated in Schedule 2 of the National Minimum Standards has been obtained for the new staff. The employer must ensure that the new staff does not work alone with service users. The employer must ensure that the new staff has identified senior members of staff to supervise them on each shift. The employer must ensure that the new staff completes induction training during this period. • • • • • The registered provider is required to ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards before starting work with vulnerable people. The registered provider was able to produce documentary evidence of staff attendance of a variety of different training courses that were relevant to the work staff were expected to perform, however the registered provider must ensure that all staff are up to date with their mandatory training. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 19 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): 31,33,36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered provider must appoint an individual with the qualifications, skills and experience to manage the care home thus ensuring that the home meets its stated purpose, aims and objectives. Generally the health, safety and welfare of the service users and staff were being promoted and protected. EVIDENCE: Since the last inspection the registered provider stated that he has not found a suitable candidate to be the manager of the home. The home has been without a manager for eleven months and this has had an impact on the day-to-day operation of the home. There are a number of requirements during this inspection. The Commission cannot allow this situation to deteriorate. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 20 Therefore the registered provider is required to employ a manager who qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Quality assurance tools currently include service user meetings, user/relatives satisfaction surveys, auditing and a complaints system. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. The registered provider stated that all staff would be having their annual appraisal in July. Certificates relating to health and safety were up to date servicing certificates. These included electrical wiring and installation, gas safety and fire safety. Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 3 Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that the administration/nonadministration of all medication is recorded accurately. The registered person must ensure that the allergy section on the medication profiles is complete for all service users. The registered person must ensure that clear directions for administration are in place for all items of medication. Timescale for action 29/06/06 2. OP9 13(2) 15/07/06 3. OP9 13(2) 15/07/06 4. OP9 13(2) The registered person is required 15/07/06 to carry out a risk assessment on service users who self-medicate. The registered person must ensure that items of medication that are out of date are disposed of as soon as possible. The registered provider must ensure that 50 per cent of the care staff must have a NVQ 2 qualification within the allocated DS0000019027.V301362.R01.S.doc 5. OP9 13(2) 29/06/06 6. OP28 18(1) 31/12/06 Hayes Court Version 5.2 Page 23 time. 7. OP29 19 The registered provider is required to ensure that new staff has all documentation as stated in Schedule 2 of the National Minimum Standards before starting work with vulnerable people. The registered provider must ensure that all staff are up to date with their mandatory training. 29/06/06 8. OP30 18(1) 30/09/06 9. OP31 8 and 9 The registered provider is 30/09/06 required to employ a manager who qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 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 that the service user’s guide be made available in formats suitable for the service users for whom the home is intended (e.g. appropriate languages, pictures, video, audio or explanation). Hayes Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Court DS0000019027.V301362.R01.S.doc Version 5.2 Page 25 - 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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