Inspection on 30/11/05 for Hook Hall

This inspection was carried out on 30th November 2005.

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

Hook Hall 12/09/06

Hook Hall 24/02/06

Hook Hall 22/02/05

Hook Hall 09/09/04

Hook Hall 09/03/04

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 Hook Hall High Street Hook Goole East Yorkshire DN14 5PL Lead Inspector Diane Wilkinson Unannounced Inspection 30th November 2005 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 Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hook Hall Address High Street Hook Goole East Yorkshire DN14 5PL 01405 767891 01405 767891 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) Mr James Douglas Ford Mrs Margaret Elizabeth Wrightson Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Hook Hall is a privately owned care home that lies within its own grounds on the edge of the quiet village of Hook, and is a listed building. The home is registered to provide care and accommodation for 21 older people, including those with dementia. The property is extremely well maintained both inside and out, and shared accommodation is in keeping with the original features of the hall. All bedrooms are single, and sixteen of these have en-suite facilities. Service users are able to access all areas of the home via the use of a passenger lift and ramps. There is a car park to the front of the building. Services in the village are limited to a post office/shop and a village pub, but the registered provider frequently transports service users into the nearby town of Goole for shopping and for visits to health professionals, family/friends and social events. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours, including preparation time prior to the inspection. The inspection consisted of examination of documentation, including care plans, and a tour of the premises. The inspector spoke to service users in a group setting, two service users ‘one to one’, the registered manager and the registered provider. What the service does well: What has improved since the last inspection? Any suggestions made at service user meetings are recorded and progress is fed back to service users at the next meeting. If the suggestion has not been actioned, the registered manager attends the meeting to explain why. Care planning documentation now includes a typed copy of all visits by health professional to enable easy reference to be made to these at reviews. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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 Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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 Service users only move into the home if a needs assessment evidences that their needs can be fully met. EVIDENCE: Care plan records evidence that a full assessment of a service user’s needs takes place prior to any decision being made about admission to the home. Service users are visited at home or in hospital by the registered manager as part of the assessment process. Service users are only offered a place at the home if their needs can be fully met and if it is considered that the person concerned is compatible with current residents. Community care assessments and care plans from care management are obtained by the home when service users are being funded or placed by a local authority. The information gained during the assessment process and any information obtained from care management and others is used to commence the development of a plan of care. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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, 9 and 10 Each service user has a thorough care plan in place that is reviewed regularly, and that evidences that health, personal and social care needs are met. The systems for the administration of medication are very good and protect the health and safety of service users. Service users report that privacy and dignity is respected at all times. EVIDENCE: Care planning at the home is very thorough. They include appropriate risk assessments for nutritional screening, pain control, falls, behaviour and pressure care and an overall summary of the risk assessments undertaken is produced. A dependency levels assessment is also completed. Daily reports record in detail the personal care that has been provided by staff to meet the needs that are recorded in the service user’s care plan. Labels are used to highlight specific topics that are recorded in daily notes, for example, a yellow label indicates that the GP has visited and the information is cross referenced to the GP visits sheet. Records include a key worker diary. Each key worker has a file of useful information ready for use – this includes a Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 10 complaints form, information about advocacy, checklists and a copy of care plan reviews (that have been signed by service users). There is a record of all contacts with health professionals and others. Monthly reviews of the care plan are undertaken and recorded, and risk assessments are also reviewed on a monthly basis. Medication policies, procedures and records are very thorough. One service user has chosen to self medicate and records show that an assessment has taken place to evidence that this is safe. There is a list of all staff that have been trained to administer medication kept with medication administration sheets. All care staff undertake a general medications training course and staff that administer medications undertake accredited medications training. Service users report that they are treated with dignity at all times, and that their right to privacy is respected. For example, one service user likes to do some of her own washing and some service users like to spend the whole day in their bedrooms – these wishes are accommodated by the home. All service users are accommodated in a single room and most service users have ensuite facilities. There are also private areas of the home where service users can meet visitors. Service users see health professionals in their own room, and if appropriate, are taken to the surgery to see a GP or other health professional. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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, 13, 14 and 15 Service users are supported and encouraged to maintain their chosen lifestyle following admission to the home. Links with the local community are good and support and enrich service users’ social opportunities. Friends and relatives are encouraged to visit the home and are made welcome. Service users report that meal provision at the home is very good. EVIDENCE: Care plans are a good record of a person’s social, cultural, religious and recreational interests and needs. The registered provider continues to take service users to adult education classes and social events. Staffing levels are sufficient to allow staff to spend time organising activities for service users, or spending one to one time with a service user if that is what they prefer. Service users are supported to continue with activities that they took part in prior to admission to the home. Service users are informed about forthcoming activities and activities are discussed at service user meetings. There is evidence that relatives and friends are encouraged to visit service users, and service users are supported to make visits out of the home. Service users are able to see visitors in private – all have a single bedroom and there are also private areas around the home to where service users are able to Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 12 meet with a visitor. Service users are able to choose who they see and do not see. There is evidence that the home is conducted so as to maximise service users’ capacity to exercise personal autonomy and choice. Some service users handle their own financial affairs and others are assisted by a family member or solicitor/accountant. The inspector observed that advocacy information is displayed in the reception area. Service users are encouraged to bring personal possessions into the home, and these items are listed in individual care plans. Service users have access to their personal records – they sign the monthly review record in care plans. The inspector observed that service users are able to exercise their choice in relation to food, meals and mealtimes, social and leisure activities and routines of daily living. Service users confirm that meals at the home are very good and that there is a choice of meal available at all times. The menu is displayed on the notice board and service users are informed on a daily basis about the choices available. Staff at the home are aware of how to present liquidised meals in an attractive and appealing manner. Various dining areas are used – service users who are independent use one dining room and another dining room is used for those service users who need some assistance. Some service users choose to eat meals in their own room, but most see mealtimes as a social event and as an opportunity to meet friends – service users are able to remain in the dining room for as long as they wish following meals. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 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): 16 and 18 Service users state that they are confident that any complaints made would be dealt with promptly and effectively. Service users are encouraged to make comments and complaints about the care they received. There is a system in place to monitor any complaints made to the home. Staff are aware of and follow policies and procedures that are in place to protect vulnerable service users from abuse. EVIDENCE: There is a satisfactory complaints procedure in place at the home and there is a complaints log in use - this records that there have been no complaints over the last year. There is also a ‘niggles’ box and a comments/suggestions book in use. Complaints are discussed at resident’s meetings – these meetings are chaired by one of the service users. The manager is called into the meeting at the end to discuss any complaints/concerns raised by service users at that meeting, and to report on progress made with any complaints/concerns raised at the previous meeting. A summary of complaints/niggles is recorded in the quality assurance log. Service users told the inspector that they are confident that any complaints they made would be treated seriously and dealt with in a professional manner. The home has a policy on the protection of vulnerable adults from abuse, plus policies on whistle blowing, the acceptance of gifts and financial protection. All staff at the home have attended a protection of vulnerable adults training update – this was facilitated by a private company. Most staff at the home are undertaking NVQ training and abuse is one of the topics covered. Staff have Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 14 undertaken aggression management training and behavioural risk assessments are undertaken for service users. There have been no reported incidents or allegations of abuse at the home in the last twelve months. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 15 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 and 26 Service users live in a safe, well-maintained and comfortable environment. The home is consistently maintained to a clean, pleasant and hygienic standard. EVIDENCE: The location and layout of the home is suitable for its stated purpose – it is accessible, safe and well maintained. There is a programme of routine maintenance and renewal of the fabric and decoration of the premises, and there is a record of all repairs and renewals undertaken. A risk assessment audit identifies any faulty equipment that needs to be repaired or replaced. The grounds are kept tidy, safe, attractive and accessible to service users. Laundry facilities are satisfactory - washing machines have the specified programming ability to meet disinfection standards and a sluicing facility. There are appropriate policies and procedures in place for the control of infection. The staff rota evidences that there are sufficient domestic staff Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 16 employed to ensure that the home is maintained in a clean and hygienic state at all times. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 17 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): 27, 28, 29 and 30 Good and consistent staffing levels ensure that service users are safe, and that the premises are clean and hygienic. Recruitment policies and practices at the home ensure the safety of service users. There is a training and development plan in place that evidences that appropriate staff training (including NVQ training) is taking place to ensure the health, welfare and safety of service users. EVIDENCE: Discussion with service users and examination of the staff rota evidences that there are always sufficient staff on duty to meet the needs of service users. The staff rota records the role of staff on duty, including ancillary staff. The registered provider and registered manager live on the premises and are always available. Whenever they go away, a relative moves into their accommodation so that someone remains available at all times. Agency staff are used to fill any vacant shifts. Eight of the 16 care staff have achieved NVQ Level 2, 3 or 4 in Care. Other staff are working towards this award to ensure that the requirement for 50 of staff to be qualified to NVQ Level 2 in Care can continue to be met. The recruitment records for a recently employed member of staff were examined by the inspector. The application form included the applicant’s employment history. A satisfactory CRB check and two written references were obtained prior to the person commencing work at the home. The Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 18 registered manager is aware of the availability of POVA first checks should she need to recruit a member of staff quickly. The training and development plan for 2005 to 2006 was seen by the inspector. This evidences that all new staff undertake one day’s Induction training that is facilitated by a private training provider, and that staff continue with this training over a period of six weeks via completion of a workbook. Staff have undertaken various training programmes since the last inspection, including moving and handling, fire safety, health and safety, protection of vulnerable adults from abuse and the administration of medication. Staff undertake core training as well as regular updates. There is a clear record of staff training achievements and staff training needs. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38 The home is managed by a well-qualified and experienced manager who consistently strives to improve the quality of life for service users. There is an effective quality assurance system in place that allows service users and relatives to comment on the quality of care provided by the home. The business and financial plan and current practices evidence that the home is a viable business. Current arrangements for safe working practices ensure that the health, welfare and safety of service users are protected. EVIDENCE: The registered manager is a trained nurse with many years experience in nursing and in residential care. The registered manager has completed the NVQ Level 4 in Care and has almost completed the NVQ Level 4 Registered Manager’s award. The registered manager has undertaken some training updates this year, including the protection of vulnerable adults and the Level 2 Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 20 Certificate in Health and Safety. Training records at the home evidence that all staff (including the registered manager) undertake training that equips them to update their knowledge, skills and competence, and to ensure that the conditions/diseases associated with old age are understood. The registered manager uses the Internet to source up to date information and trends – care planning documentation and policies and procedures are continually updated to reflect current good practice guidelines. There is a quality assurance and quality monitoring system in place at the home. This includes surveys that are given to service users and sent to relatives and visiting health professionals. The outcome of these surveys is published in a professional manner and is held at the reception desk, as well as being discussed at staff meetings and service users meetings. Monthly staff meetings are held and a service user chairs service user meetings, and prepares the minutes of the meeting. Regular audits take place on topics such as complaints, health and safety, staff training and maintenance and these are recorded. There is evidence that policies, procedures and practices are regularly reviewed in light of changing legislation and good practice advice. Service users are told about planned CSCI inspections and are encouraged to speak to the inspector. There is appropriate insurance cover at the home. There is evidence that records are kept of all transactions entered into by the registered person. The business and financial plan for the home is now available and open to inspection, and all indications are that the home is a financially viable business. Evidence indicates that service users are encouraged to manage their own financial affairs for as long as possible. The registered manager stated that current service users either manage their financial affairs, or are assisted by family members to do so. No monies are held by the home on behalf of service users. The home pay for expenses incurred by some service users, such as shopping and hairdressing, and then sends an account to the relative dealing with the individual’s finances. Secure facilities are provided for the safekeeping of money and valuables held on behalf of service users when this is needed. There is evidence that the registered manager ensures so far as is reasonable practicable the health, safety and welfare of service users and staff. Recruitment, induction and training records evidence that staff undertake training on safe working practice topics and are aware of their responsibilities around health and safety. All equipment is appropriately maintained. Inhouse fire tests take place on a weekly basis and the home undertakes a 3 monthly fire safety audit. There is a fire risk assessment and a resident’s fire risk assessment in place. The most recent fire drill was held on 25.9.05. An approved contractor checked the fire system on 23.9.05. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 21 A test to detect the presence of Legionella in the water system was undertaken in October 2005 and was negative. Weekly checks on the call system, water temperatures and radiator/room temperatures take place and are recorded. A weekly risk assessment of the building also takes place. The electrical installation is not due to be tested again until March 2006 and a portable appliance test took place in September 2005. Accidents are recorded and reported appropriately. The registered manager provides a written statement of the policy, organisation and arrangements for maintaining safe working practices, including appropriate risk assessments. All other requirements are met. Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 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 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 X X 3 Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Hook Hall DS0000019683.V261639.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!