CARE HOMES FOR OLDER PEOPLE
Headingley Hall 5 Shire Oak Road Leeds West Yorkshire LS6 2DD Lead Inspector
Paul Newman Unannounced Inspection 6th February 2006 09:45 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 Headingley Hall DS0000001460.V275941.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. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Headingley Hall Address 5 Shire Oak Road Leeds West Yorkshire LS6 2DD 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) 0113 275 9950 0113 275 9950 Westward Care (Yorkshire) Limited Miss Judith Ramsdale Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th August 2005 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 DS0000001460.V275941.R01.S.doc Version 5.1 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 10 August 2005. There have been no further inspections until this unannounced visit although two additional visits have been made in connection with an extension to the building and kitchen improvements that will be completed early in April 2006. 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 and also to assess progress in the way the home is dealing with issues that were raised in the last inspection report. 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, three other members of staff, nine residents and four relatives. 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. The inspection started at 09:45 and lasted for four hours. Not all National Minimum Standards were inspected during this visit, but over the two inspections all core standards have been inspected at least once. To gain a full picture of how the home meets standards, this report should be read in conjunction with previous reports. What the service does well:
There is nothing to add to the comments made in the last inspection report and the same comments apply. The home continues to be consistently well managed, with a clear approach to the care of residents whose quality of life and best interests 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. Residents and relatives appreciate the staff and are confident in them. There is a varied and interesting activity programme that residents are fully involved in planning. Residents’ rooms are personalised with their own belongings and they exercise choice about spending time in their bedroom or in communal areas. Varied menus provide choice and residents say that the food is good. Record keeping is clear and up to date.
Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 6 Some additional comments made in the survey questionnaires that were returned were: ‘The manager and staff are very competent and caring. Food and cleanliness is excellent. Overall this is a well run home with very caring staff’. ‘Very satisfied. Residents are treated with courtesy and care. Excellent social programme to stimulate and integrate residents’. 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 contacting your local CSCI office. Headingley Hall DS0000001460.V275941.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 Headingley Hall DS0000001460.V275941.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. Residents’ needs continue to be properly assessed before they move into the home. Well informed and knowledgeable staff meets these needs. EVIDENCE: Three care plans were checked. A detailed pre-admission assessment for each of the residents was on file and the information was accurately used to form the basis of a care plan. The staff spoken with had a good knowledge of the residents care needs and their personal preferences. The shift handover was observed and the assistant manager on duty made sure that all staff coming on duty were aware of how each of the residents was and of any problems that might need to be observed or addressed. Residents said that the staff are very caring. In the survey questionnaires that were returned relatives were very satisfied with the overall care provided and the caring qualities and competence of the staff as were the relatives spoken with during the visit. Headingley Hall DS0000001460.V275941.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, 8, 9 and 10. Care plans provide staff with clear, and up to date information and guidance to follow. The health care needs of residents are met with good cooperation and liaison with local health care services. Policies, procedures and practices for the storage and administration of medication are safe. Staff are aware of residents’ needs and treat residents with dignity and respect. EVIDENCE: Three care plans were checked. These continue to provide 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, the optician and dentists was recorded. Residents spoken with were very clear that staff kept a watchful eye on them and called the Doctor when necessary. They talked about the support from community nurses also. The assistant manager talked through medication policies and procedures and the storage and disposal of medication was checked, as were the drugs administration records. These were sound.
Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 10 As was previously the case, residents said that staff gave them good support, gave assistance when they needed it and respected their privacy like knocking bedroom doors before entering. Observations throughout the visit showed staff to be professional but personable with residents and relatives. The relationships were warm and friendly. Residents looked well cared for. Staff were observed to manage the residents sensitively. Headingley Hall DS0000001460.V275941.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, 14 and 15. There have been no changes and further developments and innovation. 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: Previous inspection reports have commended the approach taken to providing activities and the level of resident involvement in this. In the home’s review of activities 391 single activities have been provided over 2005. These range from music/singing, outings, art/craft, film shows, talks, special parties and concerts, visits from politicians, shopping trips, religious services, book reading and poetry, writing and acting their own play and cookery demonstrations. This list is not cover all. On the day of this visit on arrival some residents were in the dining room doing an exercise session with the activity organiser. Later about fifteen residents attended a musical appreciation session listening to music from the movies. The activity organiser works flexibly and this enables activities to take place during the evenings and weekends as well.
Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 12 The relatives spoken with said that they are made to feel very welcome in the home. They said that the staff communicate well and let them know of changes and problems with their relatives care. They commented positively on the good food and the activities that are provided. The residents are free to spend time on their own or join in activities and it was clear that some had struck up good friendships and enjoyed spending time with each other. They confirmed that they choose when to get up and when to go to bed. Some have telephones to keep in more regular contact with family and friends. They are happy with the additional services provided by the hairdresser and chiropodist. Some are independent enough to go out to the local shops and facilities independently. The chef continues to be a popular figure in the home and was seen at one point chatting to some residents about the meals. He has previously given cooking demonstrations but this has been extended to an activity similar to the TV programme ‘Ready Steady Cook’ - ‘Ready Steady Gerry’ – and the first of these sessions is planned during February. All of the meals provided have a choice available and residents’ personal preferences and special dietary needs are recorded. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. Staff are trained in understanding and recognising abuse and there are clear procedures for them to follow. 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. Residents and relatives said that they feel comfortable in talking to staff about things that worry them and felt that staff listen to them and put things right. There are adult protection policies that link to multi agency procedures and there is a whistle blowing policy. There are standard questions asked at interview so that the home gets an idea of the prospective member of staffs views and approach to abuse. Staff spoken with confirmed that they receive training on abuse and know that the policies and procedures are there to be followed. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following 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: There are extensive development plans for the building and the first phase of this is underway and due to be completed early in April 2006. This is going to provide an additional four en-suite bedrooms on the first floor and a kitchen extension. This appears to have been well planned with little inconvenience to residents and they are kept informed of what is going to happen. All the communal areas, the kitchen, 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,
Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 15 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 these will be included in the next phase of the development of the building. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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. The staff are experienced, well trained and know what they are doing. They have good relationships with the residents and care for them well. Recruitment policies and procedures make sure that staff are properly selected and vetted before they start work. EVIDENCE: The staff spoken with were confident and had a good knowledge of the residents they care for. There is a core of established and experienced staff who have worked at the home for a considerable time. Morale was good and the staff talked about the good teamwork. All talked about training that they had been involved with and this covered key areas of safe working practice and National Vocational Qualifications (NVQ’s). The company continues to employ a training coordinator whose role is to make sure that the staffs’ training is up to date and in line with the National Minimum Standards that are set. There are well established systems of staff meetings and shift handovers that make sure that up to date information is passed. The personnel files for two newly appointed staff were checked and found to have all the required documentation. This shows that proper recruitment procedures are followed that makes sure staff are properly checked and vetted before they take up appointment. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 32, 33 and 35. There is an open and friendly atmosphere created by good leadership and management. There is a clear approach to resident care that is person centred and puts the best interests of individual residents central to staff practice. Residents’ financial interests are safeguarded. EVIDENCE: The manager continues to be ‘hands on’ to make sure there is personal ‘on the job supervision’ and checking, as well as the established formal supervision system for the staff team. The staff and residents appreciate her management style. She has yet to complete the Registered Manager’s Award but said she was on course for completion by April 2006. The home conducts satisfaction surveys. This involves questionnaire surveys being sent to residents, relatives, staff and professional visitors. The last survey results were formulated into a report and an action plan made for any improvements that were identified. Regular residents’ meeting are held where
Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 18 they are encouraged, and do, express their views about all aspects of home life. The atmosphere in the home was warm with a lot of good humour. Staff were busy and their relationships with the residents were good. There was a lot going on with activities, personal care, the arrival of a respite care resident and a regular flow of visitors. It was a stimulating and interesting place to be and the residents were on top form. The core standard in respect of residents finance (Standard 35) was not inspected last time. Some residents’ personal monies are held for safekeeping. The records of two residents were checked and these showed transactions in and out that were supported by receipts. In both cases, a reconciliation was made with the cash held and found to be correct. Lockable facilities are also provided in each bedroom so that individuals can keep cash and valuables if they wish. Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 19 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 4 13 4 14 4 15 4 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 X X X Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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 OP31 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 new timescale agreed Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Headingley Hall DS0000001460.V275941.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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