Inspection on 30/11/07 for Hepworth House

This inspection was carried out on 30th November 2007.

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 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

Hepworth House 28/10/09

Hepworth House 10/08/09

Hepworth House 16/02/07

Hepworth House 05/12/05

Hepworth House 20/04/05

Hepworth House 13/10/04

Hepworth House 05/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hepworth House 1 St Georges Road Bedford Bedfordshire MK40 2LS Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 01:35 30 November 2007 th 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 Hepworth House DS0000014911.V346859.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. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hepworth House Address 1 St Georges Road Bedford Bedfordshire MK40 2LS 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) 01234 262139 01234 272927 hepworthhouse@waitrose.com Mr Keith Hepworth-Lloyd Mrs Prima Hepworth-Lloyd Mrs Poongothay Roy Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: Hepworth House is situated in a pleasant residential area of Bedford. It is within easy walking distance of the town centre and close to local amenities such as local shops, schools, and Churches. The home is converted from two domestic style properties. There is a garden surrounding the home, which is laid to lawn and flower- beds. There is unrestricted road parking in the area for staff and visitors. The home has undergone many changes in the last few years and currently provides accommodation for 18 residents over the age of 65 years. 16 of the rooms are single rooms with en-suite facilities. There are two lounge/diners and a sunroom on the ground floor and a lounge on the first floor. Communal bathrooms and toilets are located on the ground and first floor. The fees for this home vary from £425.86 per week for residential placements, to £455.00 per week. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 30/11/07 over 5 ½ hours by Pursotamraj Hirekar. The registered manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with provider, manager, staff, conversation with service users’ and partial tour of the building. This inspection report also includes information from the annual quality assurance assessment- selfassessment by the home. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that the MAR sheet is pre-populated with prescription and dates in accordance with the medicine received from the pharmacy. The home should ensure that the premises are redecorated as per the refurbishment and redecoration plan prepared by the home. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hepworth House DS0000014911.V346859.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 Hepworth House DS0000014911.V346859.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the assessment of needs of the service users’ and the service users’ were aware of the care and services they would receive from the home prior to their admission. EVIDENCE: The home had made appropriate arrangements for comprehensive preadmission assessment of the potential service users’. On this inspection 3 service users’ preadmission assessment records were seen. Competent staff carried out the assessments; the assessments have taken into account the social services assessments, inputs from the GP, chiropodist, dentist, and continence advisor. The assessments enabled the home and the potential service user to determine whether the home can meet the assessed needs of the potential service user’s. The potential service users are also given the opportunity to visit and assess for themselves the home had all the suitable facilities and services to offer. On this inspection there were no service user for intermediate care. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements to meet the personal and health care needs of the service users’. This was evident from the various responses Service users gave during the inspection and observations made. EVIDENCE: The home had developed detailed care plans for all the service users’, which were based on the outcomes of the needs, risk assessments, and dependency profiles. The care plans are reviewed every month on a regular basis and as and when the needs of the service users change. The care plans were updated to reflect the changing needs of the service users, for example when a service user elimination needs changed, risk assessment was carried out and revised care plan was put in place. The home had ensured that the service user, or the family member, or an advocate was engaged in the preparation of the care plans. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 10 On this inspection 3 service users were case tracked; the content of the plans seen were noted to have improved since the homes previous inspection. Guidance to staff was clear. The care plan covered aspects such as; personal care, physical well being, sleeping routines, personal hygiene, behaviour, dressing, eating and drinking, breathing, mobility, elimination, vision, hearing, oral hygiene, hobbies, continence, medication, foot care, falls, weight and build, speech, personal safety, pressure sore assessment, moving and handling, and specialist referrals. Service users through observation and discussion indicated that they had access to advice, treatment, and support from healthcare professionals. Documents seen within the individual care records showed regular visits from Doctors and District Nurses. In addition specialist referrals notes were kept within the home and staff through interviewing demonstrated that they had a good level of knowledge of the care that was being provided, and how they should support the service users. Medication records seen were noted to be sufficient. Records of medication ordered, received, and returned were kept by the home. Storage of medication was noted to be in a locked cupboard along the ground floor corridor of the home. A sealed dispensing system was being used and coloured cards were seen to be stored in the medication cupboard. However, there was confusion with reconciliation of the MAR sheet with the medicine in stock, for a service user, as the staff had noted dates on the MAR sheet with hand that did not match with the remaining stock. The staff member and the manager explained on the inspection that the medicine supply for this service user was from a different pharmacy, which did not come with a dated MAR sheet. The medicine received and the start of the medication cycle was seen and compared with the remaining stock and found that there were no medication errors. This was further supported by the written evidence provided by the Pharmacist dated 03/12/07, which was received by the commission on the 06/12/07 through the home. The pharmacist had mentioned in his communication that in future all the medicine supply would come with detailed MAR sheet. The home had maintained appropriate records for controlled drugs. The home had made appropriate arrangements to meet the personal and health care needs of the service users’. This was evident from the various responses Service users gave during the inspection and observations made. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ dietary needs were assessed and choice of menu and timings were maintained, in the interest of the service users’. The service users feel that activities provided at the home are sufficient to meet their social needs. EVIDENCE: The service users were encouraged to have their choice when decorating bedrooms and bring in their personal belongings to personalise their rooms. Service users are able to bring personal possessions into the home and the evidence of this was seen in service users’ individual rooms. Service users confirmed that they are consulted and are given choices as to how they conduct their lives within the home; choices offered included meals, activities, and relationships. Activities are on offer in the home. Information supplied by the home show that service users attend day centres, and a range of activities take place in the home including painting, drawing, games, and music entertainment. The inspector had witnessed music exercise provided by an external person as part of the ongoing weekly activity for the service users’. The service users’ those present in the lounge participated actively and appeared to have enjoyed it. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 12 Nutritional risk assessments were seen within the service users care records. A choice of meals is available, observation of the lunchtime meal showed it to be unrushed and enjoyed by the service users from their positive comments. It was also noted that service users dietary preferences based on their cultural background is taken onto account and the food menu was prepared in consultations with the service users. The kitchen was clean and neat. All service users spoken to commented on how the staffs in the home always made their friends and families feel welcome. They could see their relative in private and felt that the home was good at keeping them up-to-date on any changes concerning their wellbeing. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ were aware of the complaints procedure and were confident to use the same when necessary. EVIDENCE: The home had a comprehensive complaints policy and procedures that was accessible for the service users. The homes policy on abuse has been revised to reflect the management and reporting as detailed within the local Safeguarding of Vulnerable Adults policy. Also the home had obtained a copy of the recent multi agency guidance on how to report a suspicion or alleged abuse. Staff training records also showed that for the year 2007, 11 staff members at the home had received training in this area. The home had carried out an assessment of staff training and had maintained staff training assessment records as well. Staff members spoken to on this inspection had demonstrated awareness on the safeguarding adults and reporting on suspected abuse of service users’. There were no complaints since the previous inspection. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable environment and the home was maintained clean and tidy. EVIDENCE: The home had ensured to provide a homely environment, which was well maintained with routine maintenance programme. The home employed a handyman who deals with the day to day requirements and the home also have the services of PENINSULA to advise and assess the health and safety needs. The garden services were engaged and carried out regularly. A service user bedroom en suite toilet that had water damage on the walls reported in the previous inspection was redecorated. The provider and manager monthly meetings had covered the maintenance and redecoration of the premises on their agenda and developed suitable action plan. There was documentary evidence provided by the home that carpets have been bought and redecoration work had commenced in sitting room and carpets would be Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 15 replaced. There are also plans to replace ground floor toilet to a specialist toilet. Communal areas alongside individual rooms of service users were seen at this inspection. In the main many areas were decorated to a satisfactory standard. A couple of service users bedrooms that were seen had been decorated to reflect the choice of the service users’ which contained personal items, for example photographs, furniture and pictures. All areas were seen to be clean and free of any odours. Service users spoken with said that they found the home to be comfortable and some service users spoke of brining items of furniture in with them when they moved to the home for their individual room. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policy on staff recruitment was comprehensive. The staff had appropriate skill mix and training to do their jobs. EVIDENCE: On this inspection randomly 3 staff files were examined to look at recruitment practices at the home, all were noted to contain application forms, evidence of identification and Criminal Records Bureau checks. Evidence of a thorough selection process was in place. Staff training records were also examined and showed that staff had attended a variety of courses and workshops including health and safety, food hygiene and management of medication, fire safety, first aid, dementia care, safe guarding adults, infection control, and wound care. The home had introduced from 01/05/07 skills for care common induction standards that covered 6 units – understanding the principles of care, understanding the organisation and role of the worker, maintain safety at work, communicate effectively, recognise and respond to abuse and develop as a worker. Staffing rotas submitted by the home showed that the number and skill mix of staff were sufficient to meet the needs of the service users. Service users and staff felt that the staff ratio for the service users was enough. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 17 Staff through discussion demonstrated that they were aware of the needs of the service users as recorded within their care records and were able to describe the individual service user. It was observed that the interaction between the staff and service users was positive and showed that supportive relationships between them had been established. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had maintained good standards of care delivery and good working relations with the service users’ and their family members, staffs and relevant professionals which had been useful for appropriate care delivery and in meeting the service users’ assessed needs. EVIDENCE: The provider, manager, staff, and the service users appeared to good working relationship. The home had a new registered manager from July 2007 onwards. She was previously deputy manager at the home. Staff spoken to felt the manager was approachable and went out of her way to try and help them with their development. Service users spoken to also felt the manager was always around and they would have no hesitation in speaking to her. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 19 Staffs supervision was carried out quarterly that had enabled staff development and better care delivery in the interest of service users’. The manager and provider monthly meeting were regular which appeared to be one of the key mechanisms for quality assurance. Alongside service users meeting were held once in 3 months to identify areas of improvement and action them. The home had sent out questionnaires to relatives, service users, and visiting professionals to gain their views of the standard of care at the home. In response to the survey feedback, it was evident that the home had taken action on most of the recommendations received to improve the quality of care provided to the service users’. The home was in receipt written record of appreciation from district nurse, CPN, hair dresser, optical services, activity worker and beds contract compliance and quality assurance officer, for the quality of care provided at the home. One visitor commented ‘ the building may be old but the ethos is very up-todate and the staff are well trained. All legal requirements are on display as are policies & procedures we feel comfortable that SU is well cared for – not just looked after’ thank you to all manager and staff. A limited amount of money is managed on behalf of a small number of service users at this home. Balances checked were noted to be correct and receipts and records were in order. Documents pertaining to the management of Fire, environmental Health and internal safety checks were seen. All were up-to-date and demonstrated that required safety measures were in place to meet the relevant legislation in this area. Staff and their training records confirmed that they had been trained in a variety of Health and Safety areas including moving and handling, food hygiene and infection control. The moving and handling techniques observed during the visit were good, with appropriate use of slings and lifts, and the use of footrests on wheelchairs to avoid injury to staff and service users. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 20 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 21 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. 1. 2. Refer to Standard OP9 OP19 Good Practice Recommendations The home should ensure that the MAR sheet is prepopulated with prescription and dates in accordance with the medicine received from the pharmacy. The home should ensure that the premises are redecorated as per the refurbishment and redecoration plan prepared by the home. Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hepworth House DS0000014911.V346859.R01.S.doc Version 5.2 Page 23 - 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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