Inspection on 22/08/06 for Hazemore Retirement Home

This inspection was carried out on 22nd August 2006.

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 22/02/06

Hazemore Retirement Home 14/07/05

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 Well Lane 5 5 Well Lane Tibthorpe Driffield East Yorkshire YO25 9LB Lead Inspector Gill Sample Key Unannounced Inspection 22nd August 2006 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 Well Lane 5 DS0000019805.V309658.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. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Well Lane 5 Address 5 Well Lane Tibthorpe Driffield East Yorkshire YO25 9LB 01377 229298 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) didimo@bt.internet.com Mrs Maureen Ayris Mrs Maureen Ayris Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: 5 Well Lane is a privately owned care home which is registered to provide care and accommodation for three older people of either sex. The home is situated in the village of Tibthorpe, close to the market town of Driffield in the East Riding of Yorkshire. Information is given to new and existing service users to the home detailing the accommodation, facilities and services provided. The weekly fee is £286.80, quoted by the provider on 28th July 2006. Additional costs are made for hairdressing of between £3 and £5, and for toiletries, magazines and newspapers at cost price. All personal accommodation is provided in single rooms, and communal accommodation consists of a ground floor dining room and a living room with a dining area and balcony on the first floor, close to service users bedrooms. Bathroom, shower and toilet facilities are located on the first floor. There is a stair lift to enable service users to access both floors of the home and the garden is accessible to service users. The home is in a residential area of the village and has been adapted from a domestic dwelling to become a care home. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of a key inspection including a visit to the service which was made on 22nd August 2006. The visit focussed on the key standards and those requirements and recommendations made at the last inspection. A total of four and a half hours were spent at the visit to the service. There were two residents living at the home. Prior to the visit, the registered provider and manager Mrs. Maureen Ayris had provided information about the service and the history of the home was analysed using records held at the Commissions York office. At the visit, all of the premises were seen including bedrooms, bathrooms, living areas, the kitchen and laundry. A range of written records were also examined and practice was observed during the visit. Individual discussions with residents, Mrs. Ayris, staff on duty and one visitor formed part of the examination of key standards at the site visit, and a telephone discussion with another visitor informed the process. What the service does well: What has improved since the last inspection? Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 6 Apart from the area of quality assurance, the registered provider has made progress in addressing the requirements and recommendations made at the last inspection. While the assessment of potential service users could not be evidenced at this visit to the service, the care being provided to current service users is now reviewed on a monthly basis. The registered provider commented that this had proved useful in being able to identify changes in need and the service provided over time. 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. Well Lane 5 DS0000019805.V309658.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 Well Lane 5 DS0000019805.V309658.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): 3. Standard 6 does not apply. Quality in this outcome area is good. Service users can be assured that their needs will be properly assessed and recorded before entering the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The two service users resident at the time of the visit to the service have both lived at the home for a number of years, and one since the home was first established and registered. Checking on the assessment of potential service users prior to admission was not possible by examination of records and documentation. However, discussion with the Mrs. Ayris the registered provider and manager demonstrated that she would visit the potential service user to make an assessment of their needs, recording details of personal histories and background. Mrs. Ayris also said that she would utilise information from any purchasing authority in her own assessment. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. Service users can be assured that their health needs will be identified and met in a timely way and that their physical, social and emotional needs will be recognised and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of both service users were examined. These showed that recording had been made of all assistance which had been given to service users and noted when health issues had been identified, monitored and referred for medical assistance. The care needs and any issues which were pertinent to individual service users had been noted in monthly summaries made by Mrs. Ayris. Care plans include a record of medication prescribed to service users, and any changes made to prescribed medication by the general practitioner involved. secure storage for medication is provided by a lockable cupboard in each service users’ room. Medication was seen and records of the monitoring of blood levels for diabetes and anti-coagulation medication. Any prescribed medication for continued or short term medication is collected by Mrs. Ayris from the local surgery. One service user is given partial assistance with her medication “they put my medication out in containers and I take it when I need”. The monitoring of physical care relating to health included the Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 10 monitoring of weight and diet where this was an issue. Mrs. Ayris was heard on the telephone to the surgery discussing her concern over a test result for one service user. There was evidence that service users receive individual care: service users were served different food at lunchtime and ate their meal their own rooms. They both said that they preferred this, one saying that she stayed in her own room until after lunch and spent the afternoon in the sitting room. The arrangements for having assistance with a bath were discussed with service users, who confirmed that they are given one to one attention of the employed member of care staff. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13. 14 and 15 Quality in this outcome area is good. Daily life and social activities offers service users opportunities to live their preferred lifestyle and retain relationships in the wider community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both service users had lived at the home for a number of years. They said they were very settled at the home, “I couldn’t be happier” “I’m a country girl at heart. I have the best view – it’s countryside personified”. Service users receive regular visitors on a weekly basis and the visitors book confirmed this. A relative visited the home during the visit to the service and was able to confirm that the service was meeting her relative’s needs “I feel mum is very happy here” and when visiting “It’s just like coming to my own home”, “If I pop in any time at all it’s fine”. Service users themselves described their daily routines which Mrs. Ayris respected. The visitor said “they (service users) are always asked what they want and the service is run for their pleasure and wants”. There was evidence that the service recognises individual choices and needs. The lunch served was different for each service user based on Mrs. Ayris’s knowledge of their preference and the need for a light but nutritious meal. Service users said that they were content with their lives in the home and had opportunities to go out with relatives to local towns for shopping or trips out. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service users are able to make a complaint using information provided by the home and are protected by the awareness of staff of potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care home is also the home of Mrs. Ayris, the registered person and manager. She is present at the home for the majority of every week and is therefore available to service users and their relatives should they have a concern or complaint about the service. There have not been any complaints about the service in the last twelve months though a policy and procedure was seen detailing for any complainant the process which will be followed. Service users are protected by the policies and procedures in place at the home and their financial affairs are supported in a proper way by Power of Attorney processes. The local authority’s Protection of Vulnerable Adults policy and procedure is available at the home should any abuse be suspected or alleged. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. People living at the home live in a clean and well maintained environment which reflects a homely atmosphere. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All areas of the home were seen including two service users’ rooms, the sitting and dining rooms, bathroom and shower facilities and the home’s laundry. These areas were clean and well decorated in keeping with the style of the house and appropriate to a domestic setting. Mrs. Ayris employs cleaning staff once per week and service users said they enjoyed the cleaner’s company on her weekly visit. The home’s laundry facilities situated in the integral garage were seen which are suitable to allow soiled laundry to be washed at a high temperature to control risks of cross infection and is sited so that laundry is kept away from any area of food preparation. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. People living at the home can be assured that they will be supported by caring staff who are properly supervised staff a competent person. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered provider Mrs. Ayris is also registered as manager of the home. The home is also her own home and she is therefore on site most of the time. There is one employed care worker who is qualified to NVQ level 2 in care. At the site visit a relief care worker was present and in charge at the home while Mrs. Ayris was out shopping. She explained that she had worked at the care home before when the usual care worker was on holiday and knew the needs of both service users. A cleaner is employed one morning per week. Mrs. Ayris said she would not discriminate on any grounds when appointing new staff, and showed an awareness that there were no ethnic minorities in the village where the home is located. Mrs. Ayris said that she had not appointed any new care staff and explained the process which she had taken to employ the one care worker. She confirmed that she and other staff had had a criminal record disclosure. The registered manager has had many years experience running the care home and the one care worker has achieved NVQ Level 2 in Care. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 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 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, 35 and 38 Quality in this outcome area is good. Service users can be assured that the service is managed by a competent person whose style enables them to have any issues discussed and resolved, though the development of a formal quality assurance system would assist the manager to identify areas of service which could be improved. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home operates as a large domestic dwelling where service users Mrs. Ayris the registered provider and manager of the home has many years experience in operating the service, initially with a partner. She demonstrated an in depth knowledge of service users and their needs. She has stated that she does not intend to seek qualification to NVQ Level 4 in care and management based on her age. She has the support of staff and members of her family in the day to day operation of the home. There is no formal quality assurance system in place based on the views of service users and their relatives. Feedback is given to Mrs. Ayris on an Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 16 informal basis by service users and visitors to the home but this is not recorded. This was discussed and advice was given on how to capture this information so that Mrs. Ayris knows when expected standards are or are not being met. The call system for service users to summon assistance can be cancelled away from the point of call. However, this was tested at the visit and was fully operational. Because the care home is also Mrs. Ayris’s home and is located next to her bedroom, this means that the call system is felt to be suitable for service users as any call for assistance will be answered. A range of documents and records were examined covering the arrangements to ensure that the home complies with health and safety and other legislation. The home is fitted with smoke alarms to detect fire and records of testing of the alarms was seen up to the end of June 2006. While Mrs. Ayris said she had made the tests but had not recorded this, these records need to be made so that service users can be assured that the premises remain safe. The procedure in case of fire was seen posted about the home. A visit by the Fire Service had been made in May 2006 when no recommendations were made. Mrs. Ayris said that she had tried to get an electrician to look at the call bell system identified as needing servicing at the last inspection. The inspection of the fixed wiring at the home was also discussed as the safety of the system had not been inspected or certificated. Mrs. Ayris rang for an electrician to make an inspection of the fixed wiring during the visit to the service. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 18 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 OP33 Regulation 24 Requirement There should be a quality monitoring system in place based on the views of service users and others in measuring the quality of care provided by the home. This requirement is outstanding from the inspection made on 22nd February 2006. Testing of fire detection system must be made and recorded on a weekly basis. Timescale for action 30/09/06 2 OP38 23(4) 22/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations A copy of the electrical wiring safety certificate should be sent to the Commission. Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Well Lane 5 DS0000019805.V309658.R01.S.doc Version 5.2 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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