Inspection on 10/03/06 for Herncliffe Nursing Home

This inspection was carried out on 10th March 2006.

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

Herncliffe Nursing Home 13/02/07

Herncliffe Nursing Home 14/09/05

Herncliffe Nursing Home 14/10/04

Herncliffe Nursing Home 24/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Herncliffe Nursing Home Spring Gardens Lane Keighley BD20 6LH Lead Inspector Sean Cassidy Unannounced Inspection 10th March 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 Herncliffe Nursing Home DS0000029166.V286172.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. Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Herncliffe Nursing Home Address Spring Gardens Lane Keighley BD20 6LH 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) 01535 681484 01535 691693 P&B Kennedy Holdings Ltd Mrs Sheila Lambert Care Home 129 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (121), Old age, not falling within any other of places category (121), Physical disability over 65 years of age (121) Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for DE care is specifically for the service user named in the service provider`s letter dated 14 April 2004 Date of last inspection Brief Description of the Service: Herncliffe is in a residential area of Keighley adjacent to Cliffe Castle and other local amenities. There are parking facilities to the front of the property and a local bus stops nearby. The home is registered as a care home with nursing for one hundred and five older people. The home is divided into six units – Margaret, Constance, Terraces, Alexandra, Victoria and Garden Wing. There are three shaft lifts that access all areas of the home. Each unit has its own communal day areas as well as toilets and bathrooms. Kitchen and laundry facilities are located centrally, although each unit has its own kitchenette for making drinks and light snacks. Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to gain an overview of the care, services and facilities provided. During the inspection, records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the person in charge, members of staff, relatives and residents. 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. Two inspectors carried out the inspection. What the service does well: What has improved since the last inspection? Improvements have been made with the interior decoration and design of the home. Work continues within the home to increase its occupancy. Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 6 Improvements have been made with the care plan documentation and daily records kept for individual residents. The use of colour coding in the Garden Wing has helped improve the quality of life of the resident group living there. Domestic staff receive training in Adult Protection. 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. Herncliffe Nursing Home DS0000029166.V286172.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 Herncliffe Nursing Home DS0000029166.V286172.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): None of the above standards were inspected on this visit. EVIDENCE: Herncliffe Nursing Home DS0000029166.V286172.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): 7,9 The daily records recorded for each individual resident provide the reader with a more detailed picture of how the resident spends their day whilst living in the home. The records kept for medication administration and disposal are not consistent throughout the different units in the home. Residents would benefit from being more enabled to self medicate whenever possible. EVIDENCE: The care records were examined. These records showed that improvements have been made when recording what each individual resident did for the day. More information was available to the reader which helped form a picture of what that individual had been involved in over the course of the day and week. The home is currently developing a new care planning system. It was recommended that they take advice from the Commission for Social Care Inspection prior to implementation. The home does have a medication policy, which covers the area of self-administration. The senior management team are reviewing the medication policy at this present time. It was recommended that Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 10 they include a risk assessment that also includes a resident signature for consent. The medication charts were randomly examined in a number of different units within the home. There were a number of charts that had a significant number of gaps where medicines had not been signed for. This was highlighted to the deputy manager who gave assurances that this would be investigated. The controlled drugs records were checked and correct. Herncliffe Nursing Home DS0000029166.V286172.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 offers a varied selection of leisure activities both inside and outside which residents said they enjoyed. More evidence is needed to ensure all residents living in the home are given an opportunity to get involved with leisure activities. EVIDENCE: Residents spoken to expressed that they were quite happy with the opportunities for stimulation through leisure activities provided inside and outside the home. They said that they were consulted regarding what they wanted to do regarding leisure. The resident meetings minutes were viewed and these gave residents the opportunity to get involved with these issues. The home has developed a resident booklet, which provides them with information regarding important issues to do with the home. Two carers have been appointed to work as activities coordinators. Residents confirmed that there is a display board that keeps them up to date with what activities the home has planned for the week. Residents said that they do have people coming into the home to entertain them on a regular basis. A volunteer comes into the home every Friday to sit in the lounges and read out a local paper to residents. The residents said they looked forward to this event as it gave them an opportunity to talk about local issues and also reminisce. Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 12 There was no clear indication if residents who spend most of their time in their room have any social interactions with the activity organisers. Plans were in place for sensory equipments for the specialist unit and for staff to utilise the main wall to have team mural and for special events. Plans are in place to encourage residents to become involved with this display. Herncliffe Nursing Home DS0000029166.V286172.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): None of the above standards were inspected on this visit. EVIDENCE: Herncliffe Nursing Home DS0000029166.V286172.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): 19,26. The home has nearly completed a process of refurbishment and new build. It is clear that this has greatly improved the residents’ living environment. Residents and staff gave many positive comments about the quality and benefits of this work. However, there is still work to complete in one other unit. All those involved are confident that the completion of this planned work will also provide the same benefits to the residents living in that unit. EVIDENCE: The home is nearing the completion of the project to add new rooms and refurbish the existing building. This has been a long project which staff and residents are pleased to see that the end is in sight. The location and layout of the home is suitable for its stated purpose. The home is also in the process of applying to register 14 of its beds for residents with a Terminal Illness. Discussions were held with the deputy manager regarding the environment on Garden Wing and the contrast of this environment compared to the other units within the home. This was a very dark and dreary area that is in need of Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 15 refurbishment. The management team stated that this unit is undergoing a structural change at the present time and it is hoped the new environment would be ready by Easter. It was pointed out that the dividing wall separating the new area from the old was very dark and had Halloween images painted on it, which could potentially unnerve the resident group living on that unit. These images have obviously been there for at least three months. It was recommended that one of the painters working in the home be used to paint the wall a more calming and brighter colour. The home was clean and the control of malodours was very good. Not all hazardous substances are being locked away, in order to protect the residents from harm. It is important that when building work is carried out at the home the workmen’s equipment and substances are secured appropriately. This was discussed with the deputy manager. Herncliffe Nursing Home DS0000029166.V286172.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): 29 The recruitment process adopted by the home thoroughly protects the resident group. EVIDENCE: The recruitment files of three newly employed workers were examined and these contained all the necessary information needed to ensure the resident group are properly protected. Herncliffe Nursing Home DS0000029166.V286172.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): 33,35 The home is well managed and the interests of the residents are the main concern of the management team and staff. Record keeping, safety checks and systems of communication make sure that the home is a safe place to live. Robust systems are in place to ensure the residents’ monies held at the home are secure and accessible when needed. EVIDENCE: The atmosphere in the home is warm and friendly and the residents and relatives said that they like this. This was further supported by the comments made by residents, their relatives and visitors. Residents have the opportunity to discuss any issues during their regular group meetings or during one to one discussions with the unit managers. Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 18 One family member had devised a communication book that was kept in the bedroom of her relative, this gave visitors the ability to pass on information to one another when they visited. This book is also used by staff to get information from family and visitors. Policies and procedure for the safe keeping of valuables and monies held on behalf of residents are in place. Some resident’s rooms have a safe where their valuables can be stored. Although there was a record of all transactions taken place for monies kept on behalf of residents, the description of valuables kept for residents did not clearly describe the item and the persons involved in the process did not sign the record. The organisation prefers relatives or a nominated person to handle resident financial affairs whenever possible. For those who have no relatives, their financial affairs are handled by either Social Services the placement agency or solicitors. The Responsible person for the organisation is an appointee for four residents, whose pensions are paid directly into the home’s account. This is then used for the resident’s personal needs and a record of all transactions is kept. At the end of each month any monies left over is sent to the resident’s relatives in the form of a cheque. A mini statement is also provided to provide evidence as to how the money was spent. It was recommended that the person receiving the cheque must sign to acknowledge receipt. The systems for managing this facility were looked at in detail. An online record and a written record of residents’ personal allowance money were checked. The system is such that a resident can, at anytime of day, access money held on their behalf. This is good practice. Herncliffe Nursing Home DS0000029166.V286172.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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 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 X 17 X 18 x 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X X Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement The registered person must ensure the process for administering prescribed medication is in line with the British Pharmaceutical Guidelines. The registered person must ensure that all parts of the home are free from hazards to residents’ safety. Timescale for action 31/05/06 2. OP19 13 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP19 OP35 Good Practice Recommendations The medication policy should include a risk assessment for resident self-administration of medication. It is recommended that the care home paint the dividing wall in Garden wing a brighter and more appropriate colour. Signature should be obtained for all money handed over on behalf of residents. There should be detailed information of the items of valuable kept by the home. DS0000029166.V286172.R01.S.doc Version 5.1 Page 21 Herncliffe Nursing Home 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 © 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 Herncliffe Nursing Home DS0000029166.V286172.R01.S.doc Version 5.1 Page 22 - 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. 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