Inspection on 22/02/06 for Hazemore Retirement Home

This inspection was carried out on 22nd February 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 22/08/06

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 Diane Wilkinson Unannounced Inspection 22nd February 2006 09:30 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.V261667.R01.S.doc Version 5.1 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.V261667.R01.S.doc Version 5.1 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) HAZEMORE@SUPANET.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.V261667.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 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. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector over a period of 5 hours, including preparation time for the inspector. The inspection consisted of a tour of the premises and examination of documentation, including care plans. The inspector spoke to the three service users, the staff member and the registered provider/manager. What the service does well: What has improved since the last inspection? What they could do better: There should be a quality monitoring system and a formal staff supervision system in place. The call system must be serviced to ensure the safety of service users, and accidents should be recorded in an accident book. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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.V261667.R01.S.doc Version 5.1 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 Service user needs are assessed but this is not always prior to their admission to the home. EVIDENCE: A new service user has recently been admitted to the home. The registered manager had a telephone call from an assessment officer and the service user’s relative to ask if she could offer a place to the service user. After long discussions with the relative it was agreed that the service user would stay at the home for a two-week trial period, as the registered manager was uncertain as to whether the service user’s needs could be met. The registered manager was unable to get to the hospital to visit the service user. The period of respite has been extended as the service user has been ill with an unrelated condition since admission so it has been difficult to assess if their needs can be met. Only very brief details have been collated about this service user. Daily records are maintained. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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, 9 and 10 Care planning documentation has improved but would be further improved by the compilation of monthly summaries. Records for the administration of medication have improved and now evidence that service users receive prescribed medication. Service users report that privacy and dignity is respected at all times. EVIDENCE: Care plans are obtained from care management when this is appropriate. Care plans have been expanded as recommended at the previous inspection. Care plans now include thorough risk assessments including moving and handling, the risk of falls and the risk of pressure sores. There is also an assessment of physical needs, a record of current medication, a record of assessed needs and a plan of action. Annual reviews are held, but there is no evidence that monthly summaries of the care plan are considered or recorded. Daily records include information such as visits from family and friends, food and fluid intake and personal care details Service users informed the inspector that they are aware that records are held about them and that they are able to view these records. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 Page 10 There have been some improvements to the recording of the administration of medication. Care plans include a record of medication currently prescribed to service users, and any changes made to prescribed medication by the general practitioner. One service user self medicates and another service user has medication for the day placed in a specific container and then self-administers. Lockable cabinets are available in all bedrooms to enable safe storage. A monthly personal care sheet is used and this is where the administration of medication is recorded. GP’s provide repeat prescriptions on a monthly basis and these are collected by the registered provider/manager. All service users have their own bedroom on the first floor. They choose to remain in their rooms all day, although there is a living room/dining room and a balcony overlooking open countryside on the same floor. Service users see visitors and health professionals in their own bedroom. Service users confirmed that they are treated with respect by the registered provider/manager and the staff member, and that their right to privacy is upheld. They told the inspector that they are assisted with personal care in a sensitive manner. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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 and 14 Service users are supported and encouraged to maintain their chosen lifestyle following admission to the home. Friends and relatives are encouraged to visit the home and are made welcome. Service users are able to choose how to spend their day. EVIDENCE: Service users choose to remain in their bedrooms – they all have a television and their personal possessions around them. Service users are able to continue with interests they had before they were admitted to the home, although general frailty has restricted physical activities. Service users are provided with books, newspapers, TV guides etc. and told the inspector that they are satisfied with their current lifestyle. Visitors are made welcome at the home and care records evidence that family and friends visit the home on a regular basis. Service users are taken out by their family on occasions. Service users told the inspector that they can choose what time to get up, to go to bed, what they would like for lunch and where to spend their day. There is no information available for service users or their relatives about suitable advocacy services should these be needed by service users. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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): 18 Staff are aware of and follow policies and procedures that are in place to protect vulnerable service users from abuse. EVIDENCE: The Hull and East Riding Protection of Vulnerable Adults (POVA) policy is used at the home. The one member of staff has recently completed NVQ Level 2 in Care and studied the unit on the protection of vulnerable adults from abuse as part of this training. The registered provider/manager should consider developing a POVA policy that is specific to the home. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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): 26 The home is maintained in a clean and hygienic state. Laundry facilities are positioned so as to avoid the risk of cross infection. EVIDENCE: The laundry facilities are located in the adjoining garage and laundry does not have to be carried through the kitchen or food preparation areas. The home was clean, pleasant and hygienic on the day of the inspection. No dedicated domestic staff are employed at the home, as the home is run as a family unit. The registered manager and the care worker both undertake care duties, domestic duties and catering duties. The registered provider/manager should consider developing an infection control policy for the home. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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): 28 and 30 Staff at the home are experienced and the one member of staff has achieved an appropriate NVQ qualification. EVIDENCE: There are only two staff working at the home – the registered provider/manager and one care worker. The care worker has achieved NVQ Level 2 in Care so the requirement for 50 of staff to achieve this qualification has been met. There is no training and development programme in place and no individual record of training achievements. The registered manager has had many years experience running the care home and is planning to retire shortly and the one care worker has achieved NVQ Level 2 in Care. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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, 36 and 38 The home is well managed. There is no quality monitoring in system in place to give service users and others the opportunity to affect the way in which the home is operated. The registered provider/manager and care worker have a good working relationship but there is no formal staff supervision system in place. The call system has not been serviced and this could compromise the safety of service users. 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, as she hopes to retire in the near future. The registered provider/manager has attended 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. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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. No monies are held on behalf of service users. All service users manage their own financial affairs, or are assisted to do so by their family. All service users are provided with lockable storage to enable them to hold valuables and money securely. There is only one member of staff working at the home and there is no formal staff supervision system in place. Staff should have formal supervision six times per year. 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 care worker did inform the inspector that she works alongside the registered provider/manager and that they have a good working relationship and discuss any concerns as they arise. 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 stair lift was serviced in October 2005 and an occupational therapist has assessed the premises to ensure that they meet the needs of the service users accommodated. The call system has not yet been serviced and this should be arranged. The inspector saw no evidence that an accident book is in use at the home but accidents are recorded in daily diary sheets. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 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 that involves service users and others in measuring the quality of care provided by the home. The call system at the home should be serviced. Timescale for action 30/06/06 2. OP38 23 30/04/06 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. 2. 3. 4. 5. 6. Refer to Standard OP3 OP7 OP14 OP26 OP30 OP36 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 reviewed each month. There should be information available for service users and relatives about suitable advocacy services. The registered person should develop an infection control policy. There should be a record of the training needs and training achievements of staff. There should be a formal staff supervision system in place. DS0000019805.V261667.R01.S.doc Version 5.1 Page 19 Well Lane 5 7. OP38 Accidents should ideally be recorded in an accident book. Well Lane 5 DS0000019805.V261667.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, 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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