Inspection on 13/02/07 for Herncliffe Nursing Home

This inspection was carried out on 13th February 2007.

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

Herncliffe Nursing Home 10/03/06

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 Stephen French Key Unannounced Inspection 13th February 2007 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.V327889.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. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 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 matron@herncliffe.co.uk 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 (66), Old age, not falling within any other of places category (30), Physical disability over 65 years of age (30) Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 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 Twenty nine 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. The provider informed the Commission for Social Care Inspection on 13/02/07 that fees range from £375.00 to £620.00 per week. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Service users are able to obtain Information about the home and the services provided from the home in the statement of purpose and service user’s guide. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 13th February 2007. The inspector arrived at the home at 9:05 am and left 3:30pm. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management. The inspector read care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection 10 service user questionnaires were sent to the home to obtain service users’ views about living at the home, on writing this report none had been returned. Some service users in the home are very frail and would not be able to complete a questionnaire. There were One hundred and nineteen service users resident in the home on the day of this visit. Relative surveys were also sent out and none had been returned on writing this report. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and a pre inspection questionnaire completed by the manager. The inspection has concluded that residents’ needs, both personal and recreational, are met. Residents reside in a relaxed and informal homely environment What the service does well: Service users needs are assessed prior to them being admitted to the home to ensure these needs can be met by the staff. Service users and their relatives contribute towards the review and evaluation of their care plans. The home is well managed and there is a dedicated and competent team of staff to support the service users. The service users spoken to spoke highly of the staff saying they are kind, caring, pleasant and committed. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 6 The home ensures that service users are protected by adult protection policies, medication policies and procedures and the complaints policy. Positive interaction was observed between service users and staff. The home has systems in place to ensure a good standard of care is maintained within the home, and the views of service users are listed to and acted upon. What has improved since the last inspection? What they could do better: Staff should ensure that the standardised care plans in use are individualised by recording the type of moving and handling equipment used for individual service users. Stock balances of the previous months medication should be recorded onto the medication administration record to enable medication to be audited. The refurbishment of the home should be completed. Please contact the provider for advice of actions taken in response to this Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 7 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. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 8 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.V327889.R01.S.doc Version 5.2 Page 9 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 Service users needs are fully assessed and they have the information they need. The home does not offer Intermediate care. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that she or her deputy visits each prospective service user prior to them being admitted to the home. The purpose of the visit is to complete a pre-admission assessment to ensure the home is able to meet the needs of the service user. Following the assessment the service user is informed by letter of the date of their admission, which room they are to Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 10 occupy and the level of fees they are to pay and what the fees do and do not include. Completed pre-admission assessments were seen for three recently admitted service users confirming that the home is following their admission procedure. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 11 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 Service users heath care needs are met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection, six service users care files were examined. The home is currently introducing new documentation, which includes standardised care plans. The documentation examined contained information gathered from the pre admission assessment and community care assessment. Care plans were in place for problems identified in these assessments. Risk assessments were in place for such things as nutrition, oral health, moving and handling and skin integrity. Where assessments identified that the service user was at risk a care plan had been implemented. Care plans and assessments were reviewed monthly and there was evidence that, where they wished, service users and their family had been involved in Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 12 the review. With the introduction of printed standardised care plans staff should ensure that these are completed fully as two care plans seen for moving and handling did not inform the staff of the equipment to be used when transferring a service user from bed to chair. Service users are able to keep their own GP and staff are responsible for contacting them should the need arise. Evidence was seen that the staff have sought the advise of the continence advisor, members of the mental health team and district nurses. Service users spoken to on the day of the visit said that the staff were very kind and were always around if they required help. During the visit staff were seen to address service users in an appropriate manor and offer assistance when required. Following the last Inspection the home has introduced risk assessments for those service users who are able to self medicate, these ensure that service users self medicate safely. Qualified nursing staff are responsible for the administration of medication for service users who reside on the nursing units. Senior care staff, who have received appropriate training, administer medication to service users on the residential units. As part of the visit a selection of service users medication was audited on each unit. The medication stock balance did not tally with the medication administration records held by the home. On further investigation it was found that the previous stock of medication had not been carried forward and recorded onto the medication sheet. Although this did not pose a risk to service users this was discussed with the manager and rectified. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 13 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 Service users are able to have control over their lives. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two part time activities co coordinators who are responsible for arranging social activities within the home. The manager said that the home was currently advertising for a third person to join the team. Social activities include, amongst other things, trips out to places of interest, arts and crafts and celebrations at seasonal times of the year such as Christmas parties Halloween and bonfire night. Outside entertainers also visit the home regularly and trips out to the theatre are also arranged. The home is also part of the PAT dog scheme and the manager said that the service users look forward to them visiting. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 14 A list of activities for the week is displayed on the notice boards and service users spoken to said that they are able to join in if they wish. The home holds a church of England Holy Communion service every two weeks and a Roman Catholic communion every Sunday morning. The manager said that visiting times are open and there are no restrictions to the number of visitors, restrictions would only apply if the service user wished. Service users are able to have their meals in either the dining areas or their own rooms if they wish. The home operates a four-week menu cycle and there is a choice of two main dishes and sweets. On the day of the visit the choice for lunch was Bacon and sausage or a vegetable lasagne served with vegetables and potatoes. Staff were observed offering assistance to those service users who required help to eat their meals in a sensitive unrushed manor. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 15 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 Service users are safe and complaints are acted up on. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy, which is displayed in the reception area so anyone entering the home can have access to it. A copy of which is also contained in the service users handbook. The manager is responsible for investigating any complaint and evidence was seen that a complaint received in January 2007 had been handled appropriately. One service users spoken to said that if she had a complaint she would speak to one of the staff and she was confident that the home would resolve it. New staff receive training in the protection of vulnerable adults as part of their induction training. This training informs them of the types of abuse and what actions they are to take should they suspect any form of abuse taking place. Some of the staff have attended a training day on abuse held by Bradford Social Services. One staff member spoken to gave good responses to questions asked on this subject and was very clear in the actions she would take if she suspected any service user was being abused. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 16 Through examination of staff training records and discussion with staff it was identified that this training is not delivered regularly. In the past the home has relied on the local authority to deliver this training but this was often limited to only a couple of places therefore some staff had not received a yearly update in this area. Discussion took place between the manager and the Inspector about regular updates in adult protection training. The manager and her deputy have recently attended a two day training session on this subject and where advised to cascade this training to staff. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 17 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): 19,20,21,23,24,25,26 The service users live in a safe, well-maintained environment to which only minor attention is needed. The home was clean and fresh. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection a tour of the building was conducted, this included a number of service users’ bedrooms, communal lounges, dining rooms and bathrooms and toilets. The home has recently undergone some major refurbishment and each unit visited was in the process of redecoration and replacement of carpets. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 18 Service users’ bedrooms were personalised with their own belongings such as ornaments, pictures and small pieces of furniture. The bedrooms were decorated to a high standard and bedroom doors are lockable and the service user is given the option to hold the key if they wish. The communal lounges were bright and airy and the furniture was appropriate for this service user group, with some specialist seating for those service users who have mobility problems. There are a number of communal toilets and bathrooms situated close to the service users bedrooms and lounge areas. Bathrooms contain a number of specialist baths to enable service users to bathe safely. All of the bathrooms and toilets are fitted with track hoists to enable staff to transfer service users who are unable to stand safely. The manager informed the inspector that two bathrooms were currently being converted to shower rooms. On one of the units there is a sensory room, which can be used by service users and their relatives. The room contains fibre optic lighting a bubble tube and soft music this room is of special benefit for service users who have a dementia type illness and creates a peaceful relaxing atmosphere. The standard of cleanliness throughout the home was of a very high standard and the housekeeping staff should be commended for this. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 19 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 There are adequate numbers of trained competent staff on duty who meet the needs of the service users. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are six units within the home and each are staffed separately. The staff duty rota was examined for the month of January and February and this confirmed that the number of staff on duty is sufficient to meet the needs of the service users. The manager said that, bank staff usually covers staff holidays and sickness, agency staff are rarely used. Four staff details were checked for staff who have recently been employed by the home. The files contained application forms, interview assessments, two written references and a health questionnaire. Before any new staff are employed checks are made to ensure that the employee does not have a criminal record or appear on the protection of vulnerable adults register. Evidence was seen that the home had undertaken these checks. New staff, employed by the home complete a two-day induction course, which covers such things as moving and handling, fire and infection control. Each Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 20 new employee has a mentor who is an experienced member of staff who is responsible for ensuring that the new employee completes the Common induction standards developed by Skills for Care within the first six weeks of employment. The manager said that the home has a strong emphasis on training and evidence was seen in training records checked that staff have received training in such things as moving and handling and health and safety. The home also offers staff distance learning courses through Keighley and Shipley collage, and 61 of the 100 staff have obtained an NVQ level 2 qualification or above. Three of the Qualified nursing staff have gained a diploma in dementia care and one nurse is currently completing a six-month course on diabetic nursing. Service users spoken to said that there was plenty of staff around to give them a hand if they needed although at times they were very busy. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,38 The home is well managed and the views of the service users are sought and any shortfalls are addressed. Systems are in place to protect the health and safety of service users and staff Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is managed by a qualified nurse who has managed the home for the last four years. She has many years of experience of working with older people Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 22 and a deputy manager and six unit managers support her in her role. She has obtained the registered managers award and is aware of the needs of the service users. Evidence was seen that audits have been completed in areas of care such as care planning medication and the internal environment. These audits ensure that the expectations of the service users are being met. The home also seeks the views of the service users and relatives about the care that they receive by sending out service users questionnaires annually. The results of which are included in the homes magazine, which is produced four times a year. Returned questionnaires seen gave some very positive feedback on the care and accommodation offered. Service users are also able to air their views on the way the home is run through meetings, which are held every three months. The inspector saw the minutes of the last meeting held on the 6/12/06. It is expected that all staff receive at least six formal supervisory sessions per year during these sessions staff discuss future training needs as well as the philosophy and aims and objectives of the home. Documentation examined confirmed that this was taking place. Staff have received training in health and safety and the manager is aware of her responsibilities surrounding this. Accidents to service users and staff are recorded. Contracts are in place for such things as waste disposal, servicing of hoists and electrical equipment. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 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 3 X 3 Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 24 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 3 4 Refer to Standard OP7 OP9 OP19 OP33 Good Practice Recommendations Standardised care plans should be made more individualised and contains information on any moving and handling equipment used. The stock balances of medication remaining from the previous month should be recorded on the medication sheet. The refurbishment of the home should be completed as soon as possible to prevent further disruption to service users. The registered provider should produce an audit tool, which is completed regularly, to ensure the care and service offered by the home meet the expectations of the service users. Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Herncliffe Nursing Home DS0000029166.V327889.R01.S.doc Version 5.2 Page 26 - 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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