Inspection on 10/07/06 for Hendra House

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hendra House 16/01/06

Hendra House 25/07/05

Hendra House 10/01/05

Hendra House 06/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Hendra House 15 Sandpits Road Ludlow Shropshire SY8 1HH Lead Inspector Janet Oxley Key Unannounced Inspection 10th July 2006 9.45 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 Hendra House DS0000029315.V297024.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. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hendra House Address 15 Sandpits Road Ludlow Shropshire SY8 1HH 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) 01584 873041 01584 873075 hendrahouse@tiscali.co.uk Hendra Healthcare (Ludlow) Ltd Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (19) Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate 23 service users. The home may accommodate 19 Elderly Persons and one Person with a Mental Disorder over the age of 65 years. The home may accommodate three persons with a Mental Disorder under the age of 65 years but over the age of 60. The Commission for Social Care Inspection must be consulted with regard to all such admissions. 16th January 2006 Date of last inspection Brief Description of the Service: Hendra House is a privately owned care home registered with the Commission for Social Care Inspection to provide a service for 23 residents. The home is situated in Sandpits Road, an established residential area positioned on the northwest section of Ludlow town. The Home is owned by Hendra House Healthcare (Ludlow) Limited. Mr V Burmingham, director of the company also has day-to-day management responsibility for the Home. The building, originally a private residence, has had three purpose built extensions added in its conversion to a residential home without detracting from its original character. The accommodation is provided on two floors accessed by a shaft lift. All communal areas are on the ground floor and nineteen single and two double bedrooms on the first and second floors. Residents are able to enjoy planted out gardens and borders to the front of the building and a quiet enclosed garden and lawned area to the rear. The home makes their services known to prospective service users in: The Statement of Purpose, Service User Guide and web site which also contain their contact e mail address. The inspection report is mentioned in the statement of purpose and summarised in the service user guide. It is also on display in the entrance hall. Fees are reviewed annually and are dependant upon the type of room occupied and the dependency level of the resident. The range of fees is identified in the home’s Statement of Purpose which is available to all potential service users, their families and/or their advocates. The only additional charges to service users are for hairdressing and newspapers. This is clearly laid out in the terms and conditions. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, looking at relevant records pertaining to key standards, discussions with residents, 2 visitors, a District Nurse and the hairdresser, discussions with the staff on duty, discussion with the proprietor, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? No requirements or recommendations were made at the time of the last inspection and it has to be noted that at this home, management and staff continue to review and improve all aspects of the service to achieve best practice and maintain a good quality service. Many improvements have been made, these include improved medication procedures and risk assessments, ongoing staff development, the creation of a Deputy Care Managers post and building works have commenced on a capital project to provide additional 5 bedrooms, upgrade 5 existing bedrooms, Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 6 provide new and improved dining facilities, a treatment room for GP’s and District Nurses, a new Managers office and improved access to the front of the building. In addition to the many awards already received the home was recently nominated for the National Award for Best Small Business’s, was short listed to the last 6 and commended by the judges. The home has also won a Customer Service Award at Shropshire Business of the Year Awards Ceremony and has become the first home in Shropshire to be awarded the SPIC Gold Quality Assurance Award. 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. Hendra House DS0000029315.V297024.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 Hendra House DS0000029315.V297024.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: The home has an up to date Statement of Purpose and a Service Users Guide, which includes all the required information, and more, for prospective residents. The home has a comprehensive written procedure to be followed for all enquiries for a placement at the home, a procedure on admissions to the home and a procedure for assisting residents with settling in. Documentation examined indicated that individuals have a full and comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Particular attention is given during these assessments, not only to the needs of the prospective service user, but also of the likely effects of his/her admission will have on the existing group of residents. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 9 Significant time and effort is spent making each admission to the home personal and effective and family members and the prospective service user may visit the home as often as they wish until a decision is made Observations, inspection of records and discussions with the Proprietor, Care Manager, her Deputy and staff on duty indicated that the home meets the individual needs of the elderly people living at the home in a professional and sensitive manner. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are very well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: Personal and healthcare support in this home is offered in such a way as to promote and protect service users’ dignity and privacy in their daily life and at the end of life. It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff and residents that individual health, personal and social care needs were being met. The manner in which the care plans are maintained, regularly reviewed, continue to be developed and the professional way in which they promote the importance of the compatibility of the service user and their plan is good. Personal care monitoring is undertaken on a regular basis to ensure that staff are following the care plans and that the residents are all getting a good quality of care. A sound key worker system is in place and 2 service users were Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 11 most complimentary regarding this service. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives at the home and visiting health professionals praise the management and care standards there. Those more frail residents looked extremely comfortable and well cared for. Medication appears to be stored, recorded and administered satisfactorily and relevant staff have received the necessary training. The PCT audited the procedures on 16/05/06 and found them to be entirely satisfactory and the home is developing a quality monitoring system for all aspects on the subject. Residents individual medication is regularly reviewed and since the last inspection many improvements have again been achieved regarding the medication procedures. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 12 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): All Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Hendra House are very flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many activities take place, there is an open visiting policy and the menu offers a good choice of well balanced and wholesome meals. EVIDENCE: Individual needs, likes and dislikes are clearly shown in the care plans. Residents are certainly enabled to exercise choice and control over their own lives as far as they are able, personalise their own rooms and use them as private places. There was much evidence from discussions, observations and records to indicate that individual rights are fully promoted and each resident is supported and treated very individually. One resident continues to have 3 paper rounds, one goes on holiday alone, one attends college, 2 use the Internet, one arranges all his own medical appointments and another visits day centres. A number of activities, within the home and outside, take place to suit very individual needs and tastes and these are publicised in a Newsletter and on the notice board, recorded and monitored. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 13 Visitors are always made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors spoken to have always been complimentary regarding the quality of life for the residents at the home. The menu, meal seen and tasted, discussions with residents and 2 visitors, discussions with staff and a visit to the kitchen indicated that there is an excellent diet taken in pleasant surroundings wherever the individual prefers to eat, with sensitive help from staff. Food charts to fully record what individuals like, dislike and prefer are used. Kitchen and care staff have all undertaken relevant training and at the time of the most recent Environmental Health Officers inspection matters were satisfactory and it was considered that the management of food within the home was excellent. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 14 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 very good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and robust procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which is given to residents and their relatives before they move into the home. No complaints have been received since the last inspection by the home or CSCI. This is considered to be as a result of lack of incidents rather than lack of understanding when incidents should be reported. Residents and others associated with the home state that they are extremely satisfied with the service, feel very safe and well supported by highly aware staff. Residents are also consulted about the services received through regular questionnaires, residents meetings and 2 monthly reviews. The questionnaires have been reviewed to make them easier to complete. Outcomes from the surveys are published and collated for action by the manager. Adult protection procedures are in place. Staff are aware of these procedures and confirmed their attendance of ‘Protection of Vulnerable Adults’ training provided by Shropshire County Council. Training for new staff is arranged as necessary without delay. The home has a copy of the current Shropshire County Council Multi Agency Adult Protection Procedure, there is good liaison with other professionals and 4 POVA referrals (not involving persons employed by the home) have been professionally acted upon and policies and procedures carried out to the full. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 15 Minor concerns, received by staff at the home, from residents, are dealt with in a professional manner without delay. There is a strong key worker system in place and it was evident that management and staff respect, observe and listen to the residents. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is generally good, providing service users with a warm, safe and homely place to live. Necessary improvements have been identified and are in hand. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Bedrooms are personalised and suit individual needs and the gardens are attractive and there is a patio area with seating, easily accessible to residents and their visitors. At the time of the most recent Fire Officer and Environmental Health Officer’s inspections matters were reported to be satisfactory and advice given has been acted upon. It was evident that the manager and staff work hard to maintain this environment and further improvements, redecorating and refurbishment are in Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 17 hand and building works have commenced on a capital project to provide additional 5 bedrooms, upgrade 5 existing bedrooms, provide new and improved dining facility, new treatment room for GP’s and District Nurses, new Managers Office and improved access to the front of the building. At the time of this inspection the standard of hygiene and cleanliness was good. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 18 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): All. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well trained, well supported and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: The rotas, ratios of staff on duty at the time of inspection and the number of domestic, laundry, kitchen, administrative and maintenance staff employed indicates that the home exceeds the laid down staff complement. Recruitment at the home is thorough and all elements required by Schedule 2 of the Care Home Regulations are maintained on file. The files of 2 newly recruited staff were seen to be satisfactory and staff members were very complimentary regarding the induction, support and supervision they had received. Staff turnover is fairly low and no agency staff has been used since the acquisition of the business in 2002. The arrangements for ongoing training and foundation training are good with staff completing this well within the first six months. The home continues to support staff to undertake their NVQ awards, more than 80 of care staff have achieved NVQ level 2, 3 are completing the NVQ level 3, 4 have completed the NVQ level 3, 3 are completing the NVQ level 4, 1 is a RGN, a good variety of other training has been undertaken and staff on duty indicated that they were very sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the manager and senior staff. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 19 Recorded staff supervision, staff meetings and appraisals are undertaken in a professional manner and staff confirmed that this was so during discussions and all spoken to were complimentary regarding the management and care at the home. Training records are maintained for each staff member. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 20 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 excellent. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home reviews all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. EVIDENCE: The registered manager, is fully qualified, has many years experience and carries out his responsibilities fully with sound leadership skills promoting a professional ethos within the home. It is evident that he continues to update his own professional knowledge by attending a number of related courses to the resident group catered for. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 21 The manager involves himself fully in the day-to-day running of the home and can fully relate to all matters pertaining to the National Minimum Standards. He has recently been asked to help identify and design industry staff development and management standards, asked to join Ludlows College Employers initiative and asked to deliver RMA units at County Training and Ludlow College. The manner in which the Manager, the Care Manager and her Deputy and staff responded to this inspection indicated that a sound management approach is in place and that staff are committed to achieving best practice and to developing equal opportunities. Equality and diversity for the service users were seen to be promoted throughout the home, within the assessments, care plans and activities. Equality for staff is promoted through opportunities for training at all levels. Sound quality assurance systems are in place for all aspects of the management and care practices. There was much evidence available to indicate the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. Available for inspection were Health and Safety Statements, monthly audits, Health and Safety Management Plan, Policy and Procedural Statements, Risk Management Plan, all necessary risk assessments, full and comprehensive records on testing all necessary equipment etc. All staff have attended a health and safety training and relevant mandatory training is up to date. At the time of this inspection no potential hazards were identified. The accident records were satisfactory and it was reported that a first aider is on site at all times. Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 22 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 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 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 4 17 x 18 4 3 3 x x x 3 x 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 4 x x 4 Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Hendra House DS0000029315.V297024.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!