CARE HOMES FOR OLDER PEOPLE
Haylands 93 Crofts Bank Road Urmston Manchester M41 OUS Lead Inspector
Val Bell Unannounced 29 September 2005 10:00 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. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Haylands Address 93 Croftsbank Road Urmston Manchester M41 OUS 0161 748 3185 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) Haylands Mrs Alicia Leigh CRH Care Home PC Care Home only 24 24 Category(ies) of OP Old age registration, with number of places Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: All service users fall within the category of old age The maximum number of service users requiring personal care shall be 24. All service users accommodated are male. The home must at all times employ a manager who is registered with the Commission for Social Care Inspection. Date of last inspection 18 January 2005 Brief Description of the Service: Haylands home for retired gentlemen is registered to accomodate a maximum of twenty-four residents who require personal care by reason of old age. The home is situated within walking distance of Urmston town centre. Public transport routes are close by. The building is a large detached Victorian house with well-maintained enclosed gardens, which the residents can enjoy in fine weather. There is off road parking at the front of the property. There are twelve single rooms and six twin bedded rooms. Two of the single rooms have en-suite facilities and there are an adequate number of toilets and bathrooms on each floor. A stairlift provides access to all floors and there are additional toilet facilities on the ground floor with disabled access. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during daytime hours on Thursday 29 September 2005. Records, including care plans, were examined, a tour of the building was undertaken and conversations were held with ten residents, staff and management. Eight of the nine requirements made at the previous inspection had been addressed. What the service does well: What has improved since the last inspection? What they could do better:
Care plans lacked detail in explaining how residents assessed health and personal care needs were to be met. Additionally, care plans needed to
Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 6 contain monitoring records for residents with specific health needs such as weight loss, special diets etc. 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. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 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 standard(s) 3 Robust assessment of needs ensured that residents were appropriately admitted into the home and that the staff team had the relevant knowledge, skills and experience to provide the necessary care. EVIDENCE: Care manager assessments of need had been obtained prior to the admission of residents. The home had also implemented it’s own assessment of need. Using this documentation ensure that each individual’s needs would be identified and recorded. There was evidence that residents had been consulted throughout their assessments. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Care plans lacked the detail. This had the potential to place residents at risk of not having all their identified needs met. Residents were confident that staff would treat them with respect and respond to their requests for assistance. EVIDENCE: The requirement made at the last inspection to provide detailed care plans that explained how the identified personal and healthcare needs of residents would be met had not been addressed appropriately. From discussion with the management it was clear that this had been misunderstood. It was suggested that the home should liaise with the inspector before making changes to care plans to ensure that the correct information is recorded. The inspector was invited to visit the home five days after this inspection to look at the revised care plan format. This format was found to contain all the required information and needs to be implemented for each resident. This will be fully assessed at the next inspection. The two outstanding requirements relating to medication policies and procedures had been met since the last inspection. The home was using the
Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 10 Nomad medication system. Medication records were accurate and up to date and out of date and discontinued medicines had been returned to the pharmacy. The atmosphere within the home was relaxed and staff were unobtrusive in their interactions with residents. Staff were overheard to talk to residents in a respectful way and were responsive to requests for assistance from residents. In conversation with the inspector, residents said that staff were kind, caring and understanding. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 A lively and varied programme of activities provided stimulation and interest for residents living in the home. Meals were nutritious and balanced and offered a healthy and varied diet for residents. EVIDENCE: A varied programme of activities was available to residents. Residents told the inspector that they had been on some trips out during the summer. The homes newsletter confirmed that day trips had been provided to the Lake District, Knowsley safari Park and a boat trip. A fancy dress party had been held in March this year and photographs of the event had been posted on the notice board. A physiotherapist provided a monthly exercise class and the residents said they also enjoyed playing bingo. Parties were arranged for resident’s birthday and special occasions. The home had also introduced a confidential suggestion box to enable residents and visitors to the home to make comments and suggestions for improvements to the service. In conversation with the inspector residents said that their visitors were always made welcome and this was in evidence on the day of inspection.
Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 12 Staff were observed to encourage residents to maintain as much independence as possible and to exercise choice and control over their day-to-day lives. The inspector joined the residents for their lunchtime meal. The meal was attractively presented and nutritious. Staff were on hand to offer assistance where needed. Residents praised the quality of catering and said that they always had enough to eat and drink. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 13 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 and 18 The home’s policy and procedures on the protection of vulnerable adults ensured that residents were protected from abuse. EVIDENCE: No complaints had been received in the previous twelve months. Residents confirmed that they knew who to speak to if they had any concerns. The homes policy on the protection of vulnerable adults from abuse had been updated in accordance with the requirement made at the last inspection. Staff were able to demonstrate a thorough understanding of the correct procedures to follow in allegations or suspicions of abuse. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 14 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, 24, 25 and 26. The home’s rolling programme of development and maintenance ensured that residents were provided with a safe and comfortable living environment. EVIDENCE: The outstanding requirements relating to fire doors and upstairs windows had been addressed since the last inspection. A tour of the home was undertaken and the environment was found to be exceptionally clean, hygienic and tidy. This was commended as an area of best practice. Residents’ bedrooms had been attractively furnished and individualised to reflect resident’s personalities and preferred tastes. All bedrooms contained copies of the Service User Guide, the quality assurance document and fire evacuation procedures. The home had a development and maintenance plan and furnishings, fittings and equipment were replaced regularly. The summer bedding display in the garden was particularly attractive. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 15 Conversations were held with ten residents living in the home. Residents confirmed that they found the home to be comfortable and safe and felt that they had all the facilities that they needed. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 16 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) 29 and 30. The commitment to the training and development of staff ensured that residents were cared for by a knowledgeable and skilled staff team. Robust recruitment policies and procedures ensured that residents’ welfare was protected. EVIDENCE: Since the last inspection staff had received training in dementia awareness and training in nutrition had been arranged. The manager and deputy were also booked on a supervisors training course. Most of the care staff had achieved NVQ level 2 in care and two senior staff were undertaking levels 3 and 4. Three care staff had been recruited since the last inspection and robust recruitment procedures had been implemented. One of the deputy managers had resigned. This post remained vacant at the time of inspection. Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 17 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) 31, 32, 33 and 38. EVIDENCE: The manager had completed a course of study and had achieved NVQ level 4 in care and the Registered Managers Award. The manager also undertook additional training as part of her continuing professional development. Since the last inspection the responsible individual had begun to submit a monthly performance report to the Commission as required by Regulation 26 of the Care Homes Regulations 2001. Additionally, the home had developed and implemented a quality assurance questionnaire. The manager stated that this would be reviewed to improve its relevance to residents needs. No health and safety issues were identified during this inspection.
Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 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 3 3 4 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x x x 3 Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 19 No 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 OP07 Regulation 15 (1) Requirement The registered person must ensure that care plans contain sufficient detail to explain how residents health and personal care needs will be met. Previous timescale of 18/03/05 not met. Care plans must contain details relating to the regular monitoring of residents health needs, such as weight loss, special diets etc. Timescale for action 29/11/05 2. OP08 12 (1) (b) 29/11/05 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 Good Practice Recommendations Haylands F55 F05 S5610 haylands V241712 160805 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 OPQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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