Inspection on 10/08/05 for Headingley Hall

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Headingley Hall 08/06/07

Headingley Hall 06/02/06

Headingley Hall 30/03/05

Headingley Hall 13/09/04

Headingley Hall 04/03/04

Headingley Hall 06/06/02

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Headingley Hall 5 Shire Oak Road Leeds West Yorkshire LS6 2DD Lead Inspector Paul Newman Unannounced 10 August 2005 9.30am 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. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Headingley Hall Address 5 Shire Oak Road Leeds LS6 2DD 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) 0113 275 9950 0113 275 9950 Westward Care Miss Judith Ramsdale Care Home 33 Category(ies) of Old Age ( 33 ) registration, with number of places Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30/03/05 Brief Description of the Service: Headingley Hall is a care home that offers care and accommodation to 33 older people who have no specialist care needs. Nursing care is not provided but the home is supported by local health care services and calls on specialist advice where required. The home is a large building that has been extended with a further kitchen and bedroom extension planned. It is situated in large grounds that are shared with several cottages that are occupied by older people who receive support and domestic help from a designated support worker from the service provider Westward Care. There is a small enclosed garden area known as the courtyard to the side of the new building, Shire Oak House. There are attractive garden areas to the front of the older building that was formerly known as Headingley Hall. There is outdoor seating available to service users and visitors. Local amenities in Headingley include the Arndale shopping centre; library, public houses, supermarket and other small shops are within easy access. The Headingley Stadium is also close by. The home is serviced by good public transport links to and from Leeds city centre and more rural areas like Otley. Some off street parking is available in the grounds, to the rear and front of the home. Accommodation is provided on two floors within three distinct areas of the home that are accessible via a link corridor. Each area can be accessed by a passenger lift to the second floor. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 30 March 2005. There have been no further inspections until this unannounced visit. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided. During the inspection records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the manager, five members of staff, two relatives and seven residents. There was a planned staff meeting and this was observed. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). These cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those who replied. There was an excellent response. At the time of writing this report nine have been received from residents, this representing one third of the residents present on the day of inspection. In addition nineteen were received from relatives (a two thirds representation). Four community nurses and two doctors also responded. The inspection started at 9.30 and lasted for six hours, in addition time was spent preparing for the inspection and checking the survey responses that were received. What the service does well: The home is well managed and the interests of the residents are the main concern of the manager and staff. The staff are well organised. They are experienced, well trained, know what they are doing and have a good knowledge of the residents they care for. They have good relationships with residents and relatives who like the staff and are confident in them. Relatives feel welcome at the home and together with the residents, feel there is a warm and homely atmosphere. Some comments made were: ‘staff are friendly and easy to talk to’, ‘this is an excellent well run and organised home’, ‘always Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 6 friendly, welcoming and helpful’. Doctors and nurses who support the home are satisfied with the care provided, one doctor commenting ’standards are excellent’. There is a varied and interesting activity programme that residents are fully involved in planning. Residents’ rooms are personalised with their own belongings they exercise choice about spending time in their bedroom or in communal areas. Menus provide choice and residents are consulted about menus and encouraged to make suggestions. Record keeping is clear and up to date. What has improved since the last inspection? 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 Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 7 contacting your local CSCI office. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 8 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 Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 9 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, 4 and 5. Standard 6 does not apply to this home.l The admission process is good and includes introductory visits. Residents’ needs are properly assessed and needs are met by well-informed and knowledgeable staff. EVIDENCE: The residents and relative spoken with said that they had visited the home before they decided to live there. They all said that the staff were good and very caring and observations during the day showed relationships to be warm and personable. The four pre-admission assessments that were looked at were clear and had involved the resident and/or relative when they were being prepared. The residents were confident in the staffs’ abilities and both relatives said that the home kept her informed about changes in health and care needs. Positive comments made during the day were supported by written comments made in the survey questionnaires completed by residents, relatives and healthcare professionals. Conversations with all the staff found them knowledgeable about individual residents needs, their daily lifestyle Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 10 preferences. Systems of communication are well established to make sure that the right information is passed on a daily basis Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 11 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, 10. The healthcare needs of residents’ are met and care plans provide clear and detailed instruction for staff to follow. Staff are aware of residents’ needs and there is good communication amongst the staff group and with healthcare professionals. Residents are treated with respect and in a dignified way. EVIDENCE: Four care plans were checked. These provided staff with clear information about the care needs of individual residents and guidance about the way to deliver the care. The plans are evaluated each month and changes are recorded. Risk assessments are also included and these were also subject to review and were up to date. Liaison with doctors, nurses, dentists, the optician and dentists was recorded. Four community nurses and two Doctors completed survey questionnaires. These were positive indicating that the home’s staff communicate well, seek appropriate and timely advice, demonstrate a clear understanding of residents individual needs. An additional comment made by one doctor was ‘excellent standards’. Residents looked well cared for. The way that staff were observed to manage the residents was sensitive and caring and survey questionnaire results indicated that staff are held in high regard. Residents said that staff gave them good support, gave Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 12 assistance when they needed it and respected their privacy like knocking on bedroom doors before entering. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 13 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, 15. There is a programme of activities that is varied and interesting and residents are fully involved in the planning of this. The flexible work pattern of the activity organiser increases opportunities that are available including involvement with community organisations, projects and trips. Residents are encouraged to make their own decisions about their lifestyle. Family, friends and visitors are welcomed at the home. The chef is innovative in his approach to encourage residents to think about food, enjoy it and contribute to menu planning. EVIDENCE: The home has previously been commended about its approach to the planning and organisation of activities. The home employs an activity organiser who works flexible hours and is clearly committed to arranging activities that suit the collective needs and, as far as is possible, the individual needs of service users. Each week the ‘plotters‘ group (a residents group) meet with the organiser to establish activities over the next week and in the longer term. Activities are varied and challenge the mind, body and soul of service users. Examples are art and flower arranging, beetle drives, dominoes, music to movement, gardening, competitions and quizzes, music and literature groups, singing groups, book writing group, bridge club, mobile library; trips out to places of interest or a pub lunch or shopping; garden parties and visits from Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 14 local clergy or attendance at local churches. Activities are recorded and over the six month period prior to the inspection 220 activities had taken place. The home has been involved in International day for Older people and with a local community group, ‘Older Active People’ whose events are supported with some resident involvement. The home has featured in local newspapers having been recognised with a plaque from the Civic trust as a building, dating back and being mentioned in the Doomsday Book, a millennium of history. This type of event stimulates the residents and creates links with the immediate and wider community. Comments made during the visit and further evidenced in the survey questionnaire results indicate that family and friends are welcome to visit at any time. They feel that staff are approachable, friendly, welcoming and easy to talk to. Residents enjoy a large degree of freedom and choice about their daily routines like getting up and going to bed. Some have telephones to keep in more regular contact with family and friends. They choose whether to join in activities and how to spend their time during the day. Some are independent enough to go out on their own or potter about in the garden. The home has employed a new chef since the last inspection. He is clearly a popular individual with the residents and as one resident commented, ‘puts himself out to talk to you’. He is keen to involve residents in thinking about the food they eat and to enjoy it, so he welcomes their comments and their ideas for menus. He has put on some cookery demonstrations that proved popular with the residents. Personal preferences and special dietary requirements are recorded. The menus seen provided choices at each mealtime. Comments made and results of the survey questionnaires were positive. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 15 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 17. Residents and relatives feel comfortable in raising concerns on a day-to-day basis and have access to a formal complaints procedure that is clear. EVIDENCE: There is a complaints procedure that is clear. This is appended to the statement of purpose and service user guide and is also posted on notice boards in the home. Three of the survey questionnaires that were returned from relatives indicated that they wee not aware of the procedure. It was recommended that relatives and residents are reminded of the procedure and where it can be found. It was clear from the observations during the day and from what was said, that residents feel very comfortable in raising any source of discomfort or concern, however small. Local members of Parliament were invited to the home at the time of elections. Two residents were involved in national television news reports on voting systems and commenting on how easy it might be for their generation to exercise their rights. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is safe and well maintained and offers comfortable communal lounge areas. It is well located being close to places of worship, shops, banks, pubs and restaurants. Bedrooms suit personal needs, can be personalised with your own possessions and made private. The home has aids that make things like bathing and toileting easier. Standards of cleanliness are good and it is a pleasant home to live in. EVIDENCE: All the communal areas, the kitchen, laundry and some bedrooms were seen. No health and safety hazards were noted and staff were seen doing their work properly dressed and equipped, and their practices make sure the home is clean, free from unpleasant smells and hygienic. The home is well maintained, comfortably furnished and the attractive gardens include a courtyard area. There is garden furniture that is well used in the summer months. The laundry facilities are not ideal but there are extensive development plans that include improvement of this. Indeed the development plans are to a high specification. The first phase of this is a kitchen extension and additional four bedrooms that are to be started later this year. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 17 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 and 30 The staff are experienced, well trained and know what they are doing. They have good relationships with the residents and care for them well. EVIDENCE: Five members of staff were spoken with during the inspection. They are well organised and there are well established systems of shift handovers, staff meetings that mean information about the residents is up to date. There was a planned staff meeting during this visit. This was observed, the agenda was meaningful and it was evident that staff feel comfortable in contributing to discussion. The staff spoken with knew each of the residents well and the relationships were good with a lot of warmth and humour. The care staff are supported by a team of ancillary staff, a training and development officer, social care co-ordinator and an administrator. Staff were observed to be professional but personable in their interaction and the residents spoken with, without exception, praised the staff for their caring and supportive approach. The survey questionnaire results of the Commission and the home’s conducted earlier this year, show that there is a high level of satisfaction with staff attitudes, manner and performance. The Company has a training coordinator and from the records seen and what the staff said, this makes sure that the staffs’ training is up to date and in line with the National Minimum Standards that are set. This is very good and should give people confidence that staff know what they are doing. The staff Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 18 are committed to this because they know it helps them and they said it makes them feel more confident in their work. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 19 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 The home is well managed and the interests of the residents are the main concern of the manager and staff. Record keeping, safety checks and systems of communication make sure that the home is a safe place to live. EVIDENCE: The manager is very experienced and the staff and residents like the way she manages. She has yet to complete the Registered Manager’s Award. She likes things right for the residents and personally checks that they are. On top of this there are other more formal ways of checking the standards of care like satisfaction surveys. The record keeping in the home is good. The information about residents is clear and up to date including risk assessments, and regular safety checks are made on equipment and are recorded to make sure the building is safe. The atmosphere in the home is warm and friendly and the residents and relatives said that they like this. This was further supported in Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 20 the survey questionnaire results. They said that the manager and staff are easy to talk to and you can ‘go to them for the smallest of things’. Residents said that staff responded to the emergency call system very quickly and this made them feel safe. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 21 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 2 4 4 x x x x 3 Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 22 yes 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 31 Regulation 9 Requirement The manager must complete a recognised qualification in the care and management of a care home. Outstanding from inspection report of 13/11/04 Timescale for action 31/12/05 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 16 Good Practice Recommendations The manager should remind relatives and residents of the complaints procedure and where it is available. Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Headingley Hall 20050810 Headingley Hall UN Stage 4 S1460 V242085 J52.doc Version 1.40 Page 24 - 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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