Inspection on 14/07/05 for Hazemore Retirement Home

This inspection was carried out on 14th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hazemore Retirement Home 03/07/07

Hazemore Retirement Home 22/08/06

Hazemore Retirement Home 22/02/06

Hazemore Retirement Home 19/01/05

Hazemore Retirement Home 02/09/04

Hazemore Retirement Home 14/01/04

Hazemore Retirement Home 02/09/03

Hazemore Retirement Home 24/09/02

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

CARE HOMES FOR OLDER PEOPLE 5 Well Lane Tibthorpe Nr Driffield East Yorkshire YO25 9LB Lead Inspector Diane Wilkinson Unannounced 14 July 2005 9:30 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. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 5 Well Lane Address 5 Well Lane Tibthorpe Nr Driffield East Yorkshire YO25 9LB 01377 229298 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Maureen Ayris Mrs Maureen Ayris Care Home 3 Category(ies) of OP Old Age (3) registration, with number of places 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th January 2005 Brief Description of the Service: 5 Well Lane is a privately owned care home that is registered to provide care and accommodation for three older people, both males and females. The home is situated in the village of Tibthorpe, close to the market town of Driffield in the East Riding of Yorkshire. All service users have a single room, and communal accommodation consists of a dining room (on the ground floor) and a living room with a dining area and balcony on the first floor, close to service users bedrooms. There is a stair lift to enable service users to access both floors of the home and the attractive garden is accessible by service users. There is room on the drive at the front of the property for visitors and health professionals to park their cars. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and included a tour of the premises and examination of documentation, including care plans. The inspector spoke to the three service users and the registered provider/manager (who was the only staff member present on the day). What the service does well: What has improved since the last inspection? What they could do better: The administration of medication should be recorded in more detail to provide a record of the medication taken by each service user on a daily basis. Initial assessments of a service user’s care needs should take place prior to their admission to the home and should be recorded - these should form the basis of an individual plan of care. A quality monitoring system and a formal staff supervision system should be developed. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 6 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. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_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 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_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 Informal assessments take place but records need to be maintained to evidence that service users have had their needs assessed prior to their admission to the home. EVIDENCE: The most recently admitted service user was initially at the home for respite care. This was an informal admission arranged by family and the care home, but this has now been formalised. A brief assessment was undertaken by the care worker employed at the home prior to admission but a more thorough assessment has taken place since that time. These assessments have not been recorded. Family members and health professionals were involved in the assessment and admission processes. Local authority community care assessments and care plans are in place for those service users who are funded by the local authority. There is a brief care plan in place for each service user but these need to be expanded to include details of the assistance needed by service users with daily living skills, personal care tasks and likes/dislikes. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_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 Care plans do not record sufficient details about the health, social and personal care needs of service users although it is evident from discussion that these are being met. The health needs of service users are well met with evidence of good multi disciplinary working taking place. Records for the administration of medication need to be improved to evidence that service users receive prescribed medication. EVIDENCE: The care plan that is currently in place is in the form of a ‘tick box’ record of daily events, plus a diary sheet that records care details, such as attendance at day centres, visits from health professionals and visits/trips out with family and friends. As previously recorded, care plans need to be expanded to include information about a service user’s health, personal and social care needs, relevant risk assessments and any assistance needed by care staff. The registered provider has obtained a pro forma to record risk assessments for service users and this should be put into use. The care plan should be reviewed every month to reflect any changing needs of service users. Service users informed the inspector that they are aware that records are held about them and that they are able to view these records. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 10 Involvement by health professionals is recorded in care plans, including the reason for any visits or appointments. Community nurses visit the home on a regular basis. The inspector observed that pressure care equipment has been provided for service users and this was recorded in care plans. One service user attends a day centre for physiotherapy. Discussion with the registered provider/manager informed the inspector that continence care is managed appropriately, and there is evidence that a service user’s psychological health is monitored. Changes in medication are recorded. Records are kept of a service users food and fluid intake where this is an area of concern. Special meals are prepared for service users to ensure that they have an adequate intake of food. The registered provider was advised that service users may need to be weighed as part of a nutritional screening process at some time in the future. Service users have access to all health professionals and hearing and sight tests are arranged as necessary. The recording of the administration of medication needs to be improved. There is a brief record of the medication prescribed for service users but this is not recorded on a daily basis. One of the service user’s self medicates (tablets are put into a container by the registered provider each day) but this is not made clear in the care plan. GP’s provide repeat prescriptions on a monthly basis and these are collected by the registered provider/manager. The inspector observed that one service user has had a ‘medication review’. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_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) 15 Meal provision at the home is of a high standard and meets the dietary needs of service users. EVIDENCE: Meal provision at the home is of a high standard - this was observed by the inspector and supported by service users in discussion with them. Special meals (including diabetic meals) are prepared for service users to ensure that they have an adequate food intake, and nutritional supplements are provided as appropriate. Meals provision at the home is discussed with service users and the lunchtime menu is based on their preferences and likes/dislikes. There are a wide variety of meals on offer at teatimes. The current service users have chosen to eat meals in their own rooms, although there are two dining areas that could be used by them (one on the ground floor and one on the first floor). 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 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 standard(s) 16 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: There is a basic complaints procedure in place at the home and service users spoken to said that they know how to complain and are confident that their complaints would be listened to and acted upon appropriately. Service users spoken to said that they felt that any concerns would be dealt with informally and they could not see that an occasion would arise when they would need to complain formally. There is a complaints log on display – the last recorded complaint was in July 2003 and this was dealt with and recorded appropriately. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 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 standard(s) 19 The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: The care home is a large family home that is also the home of the registered provider/manager. The home is well maintained and very comfortably furnished. It is accessible, safe and well maintained and the grounds are safe, attractive and accessible to service users. There is a balcony on the first floor to enable service users have access to fresh air and a view of open countryside if they do not wish to use the garden. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 There is a stable staff group at the home and this ensures that there is consistency of care. Staff at the home are experienced and qualified to meet the needs of the current service users. EVIDENCE: The registered provider/manager is assisted to run the home by one care worker and two domestic staff. The care worker is employed for 12 hours per week but is available to work more hours if needed. The registered provider/manager lives at the home and provides emergency cover during the night. The home was very clean and hygienic on the day of the inspection. The care worker employed at the home is undertaking NVQ Level 2 in Care and funding requirements mean that this award has to be achieved by the end of August 2005. There are no trainees employed at the home. No staff have been recruited at the home since the last inspection and there is a very low turnover of staff. All staff at the home have had a CRB check. The registered provider/manager was reminded that any new staff employed at the home would need to have two written references and a satisfactory CRB check before they commence work at the home. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 15 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, 33, 36 & 38 The home is managed by a person who has the experience and competence to carry out this role. The formal systems for service user consultation are poor with little evidence that service user views are sought or acted upon. Further improvements need to be made to ensure that the health and safety of service users and staff is protected. EVIDENCE: The registered provider/manager has had fourteen years experience in running a care home and it is evident that she has the skills and competencies required to carry out this role. She does not intend to undertake NVQ Level 4 in Care and Management. The registered provider/manager has arranged to attend a one-day Food Safety training course to ensure that her practice is kept up to date in this area of work. There are clear lines of accountability within the home. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 16 The registered provider/manager has not made any progress on developing a quality assurance or quality monitoring system for the home that obtains the views of service users, relatives and others about the care provided by the home, or that gives them the opportunity to affect the way that the home is operated. All indications are that service users and relatives are very happy with the care provided and describe the home as ‘the nearest thing to your own home you could get’. However, there needs to be a formal system in place to measure this and the registered provider/manager was given advice on how to develop such a system. Similarly, no progress has been made with a staff supervision system. The only staff member who needs to have formal supervision six times per year is the care worker – domestic staff should have formal supervision but the frequency can be decided on ‘in house’. The registered provider/manager was advised of how a formal staff supervision system could be developed that would meet the needs of a small care home. The home is maintained in the same way that a family home is maintained, with the exception of the arrangements for fire safety. The fire extinguishers have a certificate of maintenance in place until February 2006 and fire drills and fire tests are held on a regular basis. The smoke alarms are quite new and are sited at various points around the home – these are regularly tested by the registered provider/manager. The central heating/water boiler was serviced in May 2005. The call system is fully operational but has not been serviced recently, and the stair lift is five years old and the registered provider/manager was advised that this should be serviced. These issues will be checked at the next inspection. The inspector saw no evidence that an accident book is in use at the home. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 17 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 2 x x 2 x 2 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 18 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard 3 7 9 33 36 38 Good Practice Recommendations There should be evidence that service users are assessed prior to their admission to the home, and this assessment should form the basis of an individual care plan. Care plans should be expanded to include a record of the specific needs of each service user and relevant risk assessments. Care plans should be reviewed each month. The recording of the administration of medication should be improved to include a daily record of medication taken by each service user. There should be quality monitoring systems in place that involve service users and others in measuring the quality of care provided by the home. There should be a formal staff supervision in place at the home. The stairlift and the call system should be maintained on a regular basis. There should be evidence that all accidents are recorded. 5 Well Lane J53_s19805_5 Well Lane_v228615_140705_Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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