Inspection on 29/05/07 for Hayes Court

This inspection was carried out on 29th May 2007.

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 29/06/06

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 May 2007 10:00a 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.V341850.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.V341850.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 vacant post Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A variation has been granted to allow one named service user (male) under the age of 65 to be accommodated for respite care. The CSCI must be advised when the service user no longer resides at the home. One (1) place for a service user under the age of 65, requiring general nursing care, can be accommodated. 29th June 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 residents rooms, or in one of the small lounges. The range of weekly fees is between £520 and £700. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over six hours and was conducted by two inspectors from the Commission. Some times were spent looking at the policies and procedures, talking to some residents and their relatives, staff and the registered provider. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? The home has been without a manager/ head of care for some weeks, however despite this there has been some improvement in the care plans. The administration/non-administration of medication has greatly improved and is now being monitored on a regular basis. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hayes Court DS0000019027.V341850.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.V341850.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides all of the information needed for potential residents and their relatives to make an informed decision about moving in to the home. EVIDENCE: Prospective residents have the information they need to make an informed choice about where to live. The home has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a resident guide, which provides basic information about the service. The guide is available to residents in a standard format however the home management Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 9 should consider making it available in languages and/or format suitable for intended residents. Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment, then the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Intermediate care for rehabilitation and return to the community is not provided by this home. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally residents’ personal, physical and emotional health needs are being met and reviewed, however this could be further improved. EVIDENCE: Although the home has a strong belief that it is essential to involve residents and their families as far as possible in the planning of care that affects their lifestyle and quality of life, this was not always evident. Although some of the care plans have been signed by either the resident or their relative this was not so in all cases. Care plans are written in plain language that makes them easy to understand and although they included all aspects of health and nursing care not all the residents personal and social care needs had been Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 11 identified. It is also essential that care plans are regularly updated to ensure that staff meet the changing needs of the residents however this was not evident in all care plans. Most residents’ care plans contained risk assessments, which help to support them to live as near normal lives as possible. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home now arranges for health professionals to visit frail residents in the home and provides facilities to carry out treatment. The incidence of pressure sores, their treatment and outcome, are recorded in the resident ’s individual plan of care and reviewed on a continuing basis. Reviewing of residents care plans was complicated by the fact that supporting documentation such as weights, nutritional records and skin and wound care etc. is kept in individual files separate from the care plan. To ensure care staff can meet all the assessed care needs of each resident, individual files containing their supporting documentation should be introduced. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. There is evidence of some residents administering their own medication. The registered person is working towards improving the medication systems, as there have been concerns raised before with regards to the administration of medication. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. All residents have been supported by staff to dress with care, clothing was coordinated and several of the ladies had chosen to wear jewellery and apply lipstick. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. The home has developed a system for displaying information and bringing attention to community events and activities. When Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 13 residents have particular interests every effort is made by staff to help the resident maintain their interest and keep up any community involvement. However it was noted that residents do not have care plans or risk assessment relating to activities, neither were their individual record of activities, which stated the type of activity the residents had participated in nor when. Family and friends feel welcome and know they can visit the home at any time. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room; this was evident in all residents’ rooms. The dining room was very welcoming with matching tablecloths and napkins. The food in the home is of good quality, well presented and meets the dietary needs of residents. On the day of the visit there was a choice of main dish and dessert. The cook is experienced, consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Staff are trained to help those residents who need help when eating and are sensitive in their approach. Residents are able to choose to eat in their own room if they wish. Regular drinks and snacks are available. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. 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. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The homes’ aims and objectives include the rights of residents. Residents are supported to live as independently as possible, exercising their rights to make choices and decisions with assistance when needed. The home facilitates the right for all residents to vote in elections when ever possible. The home has a safeguarding adults policy and procedures. It states how staff are to respond to suspicion or evidence of abuse and how they must report incidents and concerns. All staff have under gone training. Since the last Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 15 inspection there has been concerns raised by the Local Authority concerning the care of residents. An investigation was carried out and the concerns were not substantiated. However the home has introduced procedures to ensure that improvements are made with regards to the concerns raised. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a 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 management and staff encourage residents to see the home as their own home. It provides a very well maintained, safe, comfortable, attractive home, which has all the specialist equipment and adaptations needed to meet individual resident’s needs. As well as a good selection of general aids such as hoists, the home also ensures that equipment is individualised for each resident for example pressure relief mattress. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 17 There is a selection of communal areas, according to the numbers of residents, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other residents. The bathrooms are comfortable and easy to use and include a selection of different ways to bath, for example assisted and unassisted and there are a number of toilets strategically placed around the home. The home is always very well lit, clean and tidy and smells fresh. The management has a proactive infection control policy and they work closely with external specialists, e.g. infection control, and their own staff to ensure that infections are minimised. Clinical waste is properly managed and stored. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the service users’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the service users through vigorous staff vetting. EVIDENCE: Residents and or their relatives spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered provided informed that more than 50 of staff have an NVQ level qualification at level 2. The home has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. Three staff files were Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 19 examined at random and found to contain the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. However there is a need to ensure that staff are given regular mandatory training to ensure they are kept up to date. The home is also able to recognise when additional training is needed, and attempts to plan over time to provide this training. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 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 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home management generally provides guidance and direction to staff to ensure service users receive consistent quality care. There is an excellent quality monitoring system and this ensures the home is run in a way that is in the best interests of the service users. EVIDENCE: Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 21 Since the last inspection the acting manager has resigned and the registered provider stated that he has recruited a manager who is due to start work at the home the following week. Presently the registered provider is in day-to-day control of the home assisted by one of the senior qualified nurses. Although there are areas such as the planning of care and staff supervision and training that will greatly benefit from the appointment of a manager, the provider and qualified nurses are to be commended for the way they managed the home in the interim. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The results of service user surveys are published and made available to current and prospective users, their representatives and other interested parties, including the Commission. Residents have the opportunity to manage their own money if they wish, and some facilities are provided to help keep it safe. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. However it was noted that another first level nurse is not supervising the Registered General nurses. The registered provider was asked until a manager is appointed to seek alternative arrangements to ensure that the qualified general nurses receive supervision from another first level general nurse. The home has a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements and has an action plan for undertaking the work. Certificates relating to health and safety were up to date servicing certificates. Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 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. 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 2 8 2 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 Standard No Score 16 3 17 3 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement Care plans must be generated from a comprehensive needs assessment to ensure that all aspects of the health, personal and social care needs of the resident would be met. Timescale for action 29/06/07 2. OP7 15(1) Care plans must sets out in 29/06/07 detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident are met. Care plans must be drawn up and reviewed with the involvement of the residents, recorded in a style accessible to them; agreed and signed by the residents whenever capable and/or representatives (if any). Individual records of activities must be kept to ensure that the residents are given opportunities for stimulation through leisure and recreational activities in and outside the home, which suit their needs, preferences and capacities. 29/06/07 3. OP7 15(2) 4. OP12 16(2)(n) 29/06/07 Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 24 5. OP30 18(1) Training must be arranged to ensure that all staff are up to date with regards to their mandatory training. Alternative arrangements must be made to ensure that qualified general nurses receive supervision from another first level general nurse. 29/08/07 6. OP36 18(2) 29/07/07 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.V341850.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Hayes Court DS0000019027.V341850.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!