Inspection on 16/01/06 for Hendra House

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 10/07/06

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 Terry Woods Unannounced Inspection 16th January 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 Hendra House DS0000029315.V267049.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. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 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 NONE 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.V267049.R01.S.doc Version 5.1 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. 25th July 2005 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 with older peoples needs. 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 extends to two floors. It features communal areas to 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. There is a developing staff group providing residents with consistency in a warm comfortable atmosphere. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection of the year. The inspection was unannounced and took place on 16th January 2006 between 10:00am and 12:30pm. The manager, staff on duty and residents were all very welcoming and helpful on the day. Positive comments were received throughout the inspection from residents and staff. All of the National Minimum Standards inspected were either met or exceeded confirming that the overall quality of care provided at Hendra House is very good. It should be noted that only a minimal number of core Standards were inspected on this occasion and therefore this report must be read in conjunction with the previous produced in July 2005 What the service does well: What has improved since the last inspection? A great deal of work has been completed ‘behind the scenes’ in preparation for the implementation of phase three of the building refurbishment and extension. Policies and procedures have been updated to comply with new employment and fire safety legislation. Computerised personnel records have been introduced. A new staff handbook is in place and improvements made to the quality monitoring system. More staff are accessing training opportunities as identified through their personal development plan. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 6 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.V267049.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 Hendra House DS0000029315.V267049.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 The home has a satisfactory and functional admissions procedure providing an effective needs assessment and evaluation of suitability for both privately funded residents and those placed by the local authority EVIDENCE: Hendra House continues to ensure that a full assessment is carried out with all prospective service users. Residents at are admitted via either the local social work team, directly from hospital or through a private arrangement with no social worker involvement. In all cases, a senior member of staff visits the individual at their previous residence to complete the home’s pre admission assessment. This is to identify the person’s individual needs from the home’s perspective to ensure that an appropriate service can be provided. This process is further complemented, in some cases, by a community care assessment or a hospital discharge document. Hendra House DS0000029315.V267049.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 There is a clear and consistent care planning system in place, which provides staff with the information they require to meet residents’ needs Staff are sensitive to the individual needs of each service user and meet these in a professional manner EVIDENCE: Hendra House continues to employ an effective and well-documented system of health, personal and social care planning for residents. The case tracking of residents taken from the inspector’s observations revealed a good service being provided based on identified need and resident preferences. Documentation was inspected in detail during the previous inspection and remains at a high standard. Despite a number of residents with ‘colds’ there is a clear atmosphere of well being running throughout the home. One resident has achieved the age of one hundred years and presented as extremely articulate and alert and recalled the inspector’s previous visit. She again reflected on the kindness of staff and of the considerate way in which she is being cared for. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 10 Another resident was pleased to report how well she felt after what has been a difficult year or so due to ill health. She also spoke of the kindness and efforts made by staff to support her through this time. Health care procedures have been updated to include the safe use of oxygen in the home and oral hygiene for residents. Hendra House DS0000029315.V267049.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 The home provides a good quality lifestyle for the people in residence. EVIDENCE: The owner continues to improve the daily activities organised on site at Hendra House in consultation with the residents. This ensures that residents have every opportunity to give their views on what activities they would like to have introduced. The local vicar was in attendance during the inspection to give Holy Communion. She was accompanied by a pianist to play the organ and facilitate hymn singing. Words were provided on printed sheets and residents attending clearly enjoyed the occasion, which is repeated monthly. A daily record is kept of residents’ involvement in activities as part of the quality-monitoring tool. One resident spoke of her deteriorating sight and of her inability now to read. The staff have assisted her to access speaking books from the library to continue with this pleasure. This complements her collection brought in by relatives. Another resident spoke of his interest in horse racing and was seen going out to the local betting office to indulge in his hobby. Staff interviewed reflected on the benefits to residents of the activities introduced which offers something different to do each day. Hendra House DS0000029315.V267049.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): 16 & 18 The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon The arrangements for the protection of residents from abuse are satisfactory EVIDENCE: The complaints record folder and log contained no entries and there have been no complaints received at the Commission for Social Care Inspection office during the last year. All residents receive a copy of the home’s ‘comments, suggestions and complaints’ document, at the point of admission, which contains a useful flow chart setting out the procedure graphically. Residents are also consulted about the services received through regular questionnaires. These have recently been reviewed to make them easier to complete. Outcomes from the surveys are 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. The home has a copy of the current Shropshire County Council Multi Agency Adult Protection Procedure. Hendra House DS0000029315.V267049.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): 19 The home continues to provide a comfortable, safe and constantly improving quality environment for those in residence. EVIDENCE: These standards were not fully inspected at this inspection. However, the environment was clean, tidy and free from any offensive odours during this visit. It is noted that the owner has completed two of a three-part refurbishment programme, which has contributed to bringing the home up to a high standard over the past two years. This included a state of the art kitchen, adjacent food storage facility and new laundry. Further developments, for which planning permission has been obtained, to commence in the spring of 2006 include further en suite bedrooms, alterations to the smoke room facility, a new fire escape to replace the existing wooden structure and a new build extension to the front veranda area to provide more extensive dining facilities, a treatment room for Doctors and District Nurses and an easily accessible Care Manager’s office. Hendra House DS0000029315.V267049.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): 29 & 30 There is an effective and well-supported staff group with the skills and knowledge to enable residents to enjoy a quality of life that meets their individual requirements and aspirations. EVIDENCE: The staff team remains stable at Hendra House. The ratio of care staff to service users is determined according to assessed need and according to the rota there are generally four staff on duty during the morning, three late afternoon / evening and two on duty over night. The manager, a care manager, 4 senior care assistants, two part time domestic staff and two part time cooks plus an assistant on rota, support the care staff to provide an effective service for the residents. The home operates a thorough recruitment procedure for the protection of those in residence. One useful addition is a protocol to assess the suitability of an applicant where a disclosure is presented. Amendments have also been made to the harassment procedure and the equal opportunities quality policy to include the Employment Equality (Sex Discrimination) Regulations 2005. A new staff handbook has also been introduced which sets out the terms and conditions of employment, health and safety, probation, training and support, care and support of residents and communication and record keeping. This is a well written and easy to read document designed to help staff settle into their new job at Hendra House and provide a summary of some of the policies and procedures that they will be working to. An impressive staff training achievement record is kept demonstrating the homes commitment to achieving a competent work force. Staff spoken to confirmed the training opportunities available to them. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 15 It remains commendable that 13 members of staff have completed NVQ level 2 and an additional 3 are working towards this award. Three staff have completed NVQ level 3 and a further 2 are working towards this award. One member of staff also holds the NVQ level 4 award. The home has also achieved the Investors in People accreditation. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 16 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): 36 & 38 There are very good systems in place to ensure that residents’ health, safety and welfare are promoted and protected. The manager is developing and maintaining a well-supported staff group in the home’s quest to constantly improve the service to meet residents’ aspirations. EVIDENCE: There is a comprehensive management plan in place at Hendra House to promote, protect and monitor the health, safety and welfare of residents and staff. Health and safety records are well organised and risk assessments addressing all required aspects are in place and regularly reviewed. A staff-training plan is in operation both ongoing and at the induction stage addressing safe working practices and using a risk assessment approach. A revised fire safety plan is also in place to comply with Regulatory Reform (Fire Safety) 2005. Staff training has been completed in advance of this Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 17 reform. Food safety refresher training has been arranged for six staff members in February 2006. Formal staff supervision is carried out by the manager and senior staff eight times per year. Very good records are kept with a format that directs the meeting and covers areas of agreed actions, review of performance and setting targets, training and support, performance improvement and other matters. Staff reflected on their confidence in the manager and seniors and always felt at ease to discuss matters for attention as they arise. It is also noted that a computerised system of Personnel records has been introduced which is currently running alongside the established paper documents. Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 4 X 4 Hendra House DS0000029315.V267049.R01.S.doc Version 5.1 Page 19 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.V267049.R01.S.doc Version 5.1 Page 20 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. 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