Inspection on 09/03/04 for Hook Hall

Care Home For Older PeopleHook HallHigh Street Hook Goole East Yorkshire DN14 5PLUnannounced Inspection9th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Hook Hall Address High Street, Hook, Goole, East Yorkshire, DN14 5PL Email Address james.d.ford@btinternet.com Name of registered provider(s)/Company (if applicable) Mr James Douglas Ford Name of registered manager (if applicable) Mrs Margaret Elizabeth Wrightson Type of registration Care Home No. of places registered (if applicable) 21 Tel No: 01405 767891 Fax No: 01405 767891Category(ies) of registration, with (number of places) Dementia - over 65 years of age (21), Old age, not falling within any other category (21) Registration number B050000154 Date First registered 17th July 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 1st April 2002 YES NO 21/10/03 If Yes Refer to Part CHook HallPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 39th March 2004 1.00 pm Rob PadwickID Code099274Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different N/A perspective to the inspection process Name of Specialist (e.g. N/A Interpreter/Signer) (if applicable) Name of Establishment Representative at Mrs Margaret Wrightson the time of inspectionHook HallPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementHook HallPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Hook Hall. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Hook HallPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Hook Hall is a splendid, listed building that lies within its own private grounds on the edge of the quiet village of Hook. The property is extremely well maintained both inside and out, and its keeping is very much in character with the original features of the hall. Bedrooms are all singles and 16 of the 21 have en-suite toilets. Extra facilities are available on both ground and first floors. The second floor is private accommodation. The cellars of the hall are allocated for separate laundry and food storage areas. Lounges and dining rooms include two of each. Services in the village are limited to a post office/shop and local pub, but Mr Ford (owner), provides transport for service users into the near by town of Goole and for visits to GP, hospital, friends and family, and social events. Residential care is provided to a maximum of 21 older service users, some of who may have dementia. Mrs Margaret Wrightson (manager) ensures service users have their individual rights protected and that access to all community-based services is enabled. Practices relating to care issues are of a high standard, while opportunities to relax and enjoy a fulfilling lifestyle are both numerous.Hook HallPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection took place on the 9th March 2004 and lasted for a period of 5 ½ hours. The inspector case tracked two of the service users and all those spoken to on the day were highly complimentary of the home and its staff. Service users indicated they were satisfied with the standard of care they received and that the food and accommodation was in accordance with their needs and wishes. From observation of the interactions within the home on the day, evidence indicated that service users were treated with warmth and dignity and afforded choice and flexibility in their daily lives. Evidence from this inspection indicates that the management of Hook Hall continues to deliver a good service, and that the home had only minor shortfalls before the requirements of the National Minimum Standards for Care Homes for Older People were fully met. Choice of home. The 1 Standard assessed was in met · The manager and staff indicated they had a good understanding of the needs of the service users. · Service Users received an extensive assessment of their needs. · Plans of care had been developed in order to guide staff to meet the areas of need identified. · Care plans had been categorised according to issues concerning maximisation of health, minimising stress and maximising the life potential of the individual service user. · The home operated an ongoing programme of staff training. · The manager is a registered nurse and undergoes periodic training in order to update her skills. · Specialist courses in diabetes and dementia had been accessed in order to equip staff and others were planned in the near future. · Evidence was seen around the home of aids, adaptations and hoists in order to assist the service users in maximising their independence. Health and Personal Care. The 4 standards assessed were met · Service users files were well organised, and indicated that regular monthly reviewing and that service users or their representative were in agreement with them. · Care plans included appropriate risk assessments and had been categorised according to issues concerning maximisation of health, minimising stress and maximising the life potential of the individual service user concerned.Hook HallPage 6 · · · · · ·Service users health care needs were well met. All service users were registered with a GP of their choice and the home had good access to local community health teams. The home had a policy and guidelines on the administration of drugs and staff had attended training on this. Medicines and any controlled drugs were stored, receipted, handled, administered and disposed of according to the relevant legislation and the medication supplies were randomly checked and found to be correct. Death and any accompanying rituals were handled with sensitivity, dignity and respect. Relatives were encouraged to be involved and made welcome to stay if required.Daily Life and Social Activities. The 4 standards assessed were met · Evidence indicated that service users lifestyle and preferences were met and that the home afforded them with a flexible routine of varied activities. · The homes assessment and care plans ensured that likes and interests of the service users were known and documented · Service users were able to maintain contact with friends and family and that they were encouraged to become involved in the community. · The home had an open visiting policy and discussion with the manager indicated that no restrictions were imposed unless these were at the request of the service users. · The home had close links with the local community and service users were seen to have recently taken part in a quiz raising money for the local church. · Service users were encouraged to retain responsibility for their finances. · The home had good links with the local Citizen Advice Bureau and information was seen in the home to advertise the services of a source of independent advice. · Service users files were appropriately held and inspection of the homes policies indicated that these included the right of service users to access their records. · Service users receive a wholesome, appealing and balanced diet in pleasant surroundings. · Menus were compiled according to service users likes and preferences. · Evidence given to the inspector indicated that staff had attended courses on food hygiene and nutrition at Hull College. Complaints and Protection. The 3 standards assessed were met. · The home had a complaints policy that gave timescales for action together with details of how to contact the National Care Standards Commission if required. · Service users were registered on the electoral roll · Service users and their relatives had access to an independent source of advice. · A copy of the Hull and East Riding Vulnerable Adults Procedure was available and the home had a whistle blowing policy. · Two staff had attended training on the protection of vulnerable adults and the manager hoped to organise further training on this.Environment. 6 of the 8 standards assessed were met and the others had minor shortfalls · The home was found to be clean, odour free and welcoming. Hook Hall Page 7 · · · · · · ·Hook Hall lies within its own extensive grounds, which were accessible to wheel chair users and neat and tidy. The home is a smoke free establishment, spacious in character and had two lounges and two dining rooms. Fifteen of the homes 21 bedrooms had en-suite toilet facilities. Grab rails were installed with ramps and a passenger lift giving access to all areas and a call system was in operation throughout the building, All of the service user rooms in Hook Hall to be singles with 16 of them having ensuite facilities. Bedrooms were comfortable and furnished with service users personal possessions. Rooms were clean and comfortable and suited the service users needs.Staffing. The 4 standards assessed were met · Staffing levels were above those recommended by the Residential Forum. · The home had an induction programme that met the specifications of the Training Programme for the Personal Social Services (TOPSS). · Four of the eighteen care staff employed had obtained a qualification that was at least an NVQ 2 or equivalent. · All other carers were enrolled on a course leading to this qualification. · Documentation in staff files indicated that Hook Hall was correctly following its recruitment policy and procedure. Management and Administration. 6 of the 8 standards assessed were met · The manager trained as a nurse and had obtained the Advanced Management in Care Award and was undertaking the Registered Managers Award. · There were clear lines of accountability within the home. · The management style was open, positive and inclusive. · Hook Hall had produced its own newsletter, that detailed forthcoming events, updates and information concerning the home and including contributions from service users. · The home had a system in place for monitoring the quality of its service provision, · which involved a yearly calendar of areas and issues to audit; however the home had not yet published the findings of these. · Satisfactory insurance cover was in place, however evidence of an up to date business plan was not seen · Staff files indicated that the recruitment policy was being appropriately followed with formal staff supervision occurring on a two monthly basis and including annual appraisals. · Files were stored securely and discussion with service users indicated that they could have access to their records.Hook HallPage 8 · · ·Inspection of the home indicated it to be well maintained Training had been given in moving and handling, fire safety, first aid, health and safety and other appropriate issues. Maintenance of fire equipment, gas and electricity was occurring with checks by approved engineers with certificates obtained.The requirements and recommendations outstanding from the previous inspections are listed below, followed by the requirements and recommendations identified at this inspection. The Inspector would like to thank the service users and staff for contributing to this inspection and making him feel welcomed into the life of the home.Hook HallPage 9 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 25 OP34 The registered person must ensure that there is a business and financial plan for the establishment, that is open for inspection and reviewed annually 1/1/04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard The registered manager should include details of any relevant clinical guidelines produced by professional bodies within the individual plans of care for service users. The registered person should obtain a formal assessment of the building by a suitably qualified person The registered person should take steps to increase the homes staffing levels to that recommended by the Residential Forum1OP72 3OP22 OP27CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)Hook HallPage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. The registered person must demonstrate that a suitably qualified person has formally assessed the home The registered person must ensure that the results of service user surveys are published and made available to current and prospective users, their representatives and other interested parties, including the NCSC. The registered person must ensure that there is a business and financial plan for the establishment, that is open for inspection and reviewed annually123,26OP219/5/04216,23OP229/6/04324OP339/6/04425OP349/6/04Hook HallPage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard *·Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Hook HallPage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YES 8 2 0 NO NO YES YES 18 1 9/3/04 13.00 5.5Hook HallPage 13 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Hook HallPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 259 To (£) 314Any charges for extrasYESIf yes, please state what the extras are: Hairdressing, toiletries, newspapers, dry cleaning Key findings/Evidence Standard met? This standard was not reassessed as it was met on the last inspection 0Hook HallPage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not reassessed as it was met on the last inspectionStandard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not reassessed as it was met on the last inspectionStandard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? Discussion with the manager and staff indicated they had a good understanding of the needs of the service users. An extensive assessment of the individual service users had been further extended since the last inspection and these had been developed into plans of care, in order to guide staff to meet the areas of need identified. The care plans had been categorised according to issues concerning maximisation of health, minimising stress and maximising the life potential of the individual service user. Staff were allocated to service users to act as keyworker or named staff member for them. The home operated an ongoing programme of staff training and the manager is a registered nurse who undergoes periodic training in order to update her skills. Discussion with the manager indicated that specialist courses in diabetes and dementia had been accessed in order to equip staff with professional knowledge of the associated conditions of old age, and that other were planned in the near future. Evidence was seen around the home of aids, adaptations and hoists in order to assist the service users in maximising their independence.Hook HallPage 16 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not reassessed as it was met on the last inspectionStandard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard was not assessed, as Hook Hall does not offer intermediate care.Hook HallPage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? Service users files inspected were well organised, and indicated that regular monthly reviewing of the service users progress against assessed needs was occurring. The care plans seen by the inspector indicated that service users or their representative were in agreement with them, or had had input into them. Discussion with the manager indicated that she actively monitored the care plans in order to strive to make continual improvements and that relevant clinical guidelines, produced by the professional bodies concerned with the care of older people, would be included in these in the future. Such information was seen to be held elsewhere at the time of this inspection. Care plans included appropriate risk assessments and had been categorised according to issues concerning maximisation of health, minimising stress and maximising the life potential of the individual service user concerned.Hook HallPage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)12 03 Key findings/Evidence Standard met? Evidence indicated that the service users health care needs were well met. Discussion with the manager indicated that all service users were registered with a GP of their choice and the home had good access to local community health teams. Psychological and nutritional needs were recorded and monitored regularly in the care plans, and all specialist medical requirements (hearing, sight, chiropody, etc.) attended to by local health services. The manager indicated that a district nurse visited for those who required her input and that she was available to give advice on pressure care and continence related issues. Further discussion indicated that the home liaised closely Community Psychiatric services. Service users indicated that they were very happy and satisfied with the standard of care they received and that they were confident they could access other services, if and when they might be needed. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home had a policy and guidelines on the administration of drugs and the discussion with the manager indicated that staff had attended training on this and that further training on the safe use and handling of medication was to be accessed from Selby College. Hook Hall uses the Monitored Dosage System from Boots Chemist with whom it has a contract with, for prescribed drugs and has a self-medication policy in place with a declaration form, which service users sign, should they wish to take responsibility for their own medication. Medicines and any controlled drugs were stored, receipted, handled, administered and disposed of according to the relevant legislation and the medication supplies were randomly checked and found to be correct.Hook HallPage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not reassessed as it was met on the last inspectionStandard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Discussion with manager indicated that death and any accompanying rituals were handled with sensitivity, dignity and respect. Evidence indicated that personal care was given with guidance from the District Nurse and Marie Curie Nurses when required and that this was given in private and in the comfort of their room. The manager stated that staff would remain with the service user and that families and relatives were encouraged to be involved and made welcome to stay if required. Information given to the inspector indicated that support would be given to relatives and that the home would access specialist support if required.Hook HallPage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Evidence indicated that service users lifestyle and preferences were met and that the home afforded them with a flexible routine of varied activities. The inspector observed service users making items for the forth coming Mothering Sunday whilst others choose to remain in their rooms or sitting in one of the homes lounges. Information given to the inspector indicated that the home had an extensive programme of activities and discussion with the manager indicated that this had included a recent trip to York to see Jesus Christ Superstar and that a forth coming trip was planned to see a further show on the coast. The homes maximising life potential section of its assessment ensured that likes and interests of the service users were known and documented and evidence indicated that its approach was to actively meet these in a person centred manner. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Evidence indicated that service users were able to maintain contact with friends and family and that they were encouraged to become involved in the community. On the day of this inspection, service users had attended a local college craft class whilst others went out for a meal and social event at a local pub. Information was included in its service users guide that indicated that the home had an open visiting policy and discussion with the manager indicated that no restrictions were imposed unless these were at the request of the service users. Relatives were observed to freely come and go during the inspection and discussion with service users indicated that their relatives were able to take them out for visits if required. The home had close links with the local community and service users were seen to have recently taken part in a quiz raising money for the local church.Hook HallPage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Discussion with the manager indicated that service users were encouraged to retain responsibility for their finances and that where they were unable to do so, their families to take responsibility for their affairs. The manager indicated that the home had good links with the local Citizen Advice Bureau and information was seen in the home to advertise the services of a source of independent advice. Inspection of the home indicated that service users had brought personal items and possessions with them and the manager advised that an inventory was kept of articles brought into the home in this way. Service users files were appropriately held and inspection of the homes policies indicated that these included the right of service users to access their records. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The inspector saw evidence that service users receive a wholesome, appealing and balanced diet in pleasant surroundings. Menus were compiled according to service users likes and preferences, while the actual meals taken recorded as part of the homes quality audit. On the day of this unannounced inspection the main meal of the day had consisted of roast beef, roast and mashed potatoes and 3 vegetables, followed by cheesecake. Tea was soup and a choice egg, corned or roast beef sandwiches or crumpets and fruit and ice cream or cake. Meals were treated as a social event with staff assisting discreetly if needed. The home had two small dining rooms that were homely in character, with tables set with tablecloths, napkins and condiments. Evidence given to the inspector indicated that staff had attended courses on food hygiene and nutrition at Hull College.Hook HallPage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure, which includes the stages, and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? Discussion with service users indicated they were confident that complaints would be listened to and acted upon. The home had a complaints policy that complied with the requirements of this standard, giving timescales for action together with details of how to contact the National Care Standards Commission if required. Evidence indicated that Hook Hall maintained three separate records for dealing with this area of practice. As well as the formal complaints book, the home kept a niggles book and a further communication / suggestions book. The homes complaints procedure was communicated to all service users on admission to the home, via the Statement of Purpose and Service User Guide. Practices in the home ensured that any problems that might arise, were dealt with at the time of their occurrence and therefore did not escalate to major issues.Hook HallPage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Discussion with the manager indicated that service users were registered on the electoral roll and that the home would enable service users to participate in the civic process via the use of postal votes. Information was seen to be available to give service users and their relatives access to an independent source of advice.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? A copy of the Hull and East Riding Vulnerable Adults Procedure was available in the home; along with policies and procedures to ensure that service users are protected from abuse. Hook Hall has a whistle blowing policy, and discussion with staff indicated they were aware of this if ever needed. Discussion with the manager indicated that staff were given instruction on aspects of the homes policies and procedures in regular staff meetings and via a cascading system of supervision. Discussion with the manager indicated that two staff had attended training on the protection of vulnerable adults and that a role-playing exercise on this had been included in a recent staff meeting. The manager indicated that she was hoping to arrange further training on this area of practice.Hook HallPage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Evidence from this inspection indicated that service users live in a safe and well maintained environment. The home is situated on the edge of the quiet village of Hook and lies within its own extensive grounds, which were accessible to wheel chair users and neat and tidy. The home employs a handy man and had a maintenance book to alert him to what was needed and show when work had been completed. However no record was seen of records relating to these were seen and these must be available in order to fully meet the requirements of this standard. Discussion with the manager and registered person indicated that the requirements of the environmental health department and fire service had been met. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 4 Key findings/Evidence Standard met? As a pre existing care home, evidence indicated that service users were provided with at least the same amount of communal space as they had on 16th August 2002 when the requirements for this standard were amended. Hook Hall is a smoke free establishment and was spacious in character and had two lounges and two dining rooms. Information given to the inspector indicated that any of these rooms could be available for seeing visitors in private, or that service users could use their own bedrooms for this purpose. The grounds were extensive, well maintained, and accessible for service users in wheelchairs, via ramps to several of the external doors. Lighting in all rooms was sufficient, while furniture was of a good quality and domestic in character.Hook HallPage 25 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Fifteen of the homes 21 bedrooms had en-suite toilet facilities. There were two bathrooms, one shower, and eight toilets available to those service users who did not have en-suite facilities. All of these were within close proximity of the rooms mentioned.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? Discussion with the manager indicated that before Hook Hall was officially opened in December 1995, a woman with a physical disability visited the home in order to offer advice on equipment needed. She advised tracking systems and specialist toilets, but Mr Ford declined to take this advice. However, grab rails and simple aids were installed as necessary for the service users at the time. Ramps and a passenger lift were observed to provide access to all areas and a call system was in operation throughout the building, together with the provision of various aids and adaptations. In order to fully meet this standard the registered person must demonstrate that a suitably qualified person has formally assessed the home.Hook HallPage 26 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 21 16 0 0 21 00 0 0 03 Key findings/Evidence Standard met? Evidence indicated that all of the service user rooms in Hook Hall to be singles with 16 of them having en-suite facilities. The bedrooms were in excess of the requirements for preexisting care homes and met the requirements for this standard.Hook HallPage 27 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Evidence indicated that service users bedrooms were comfortable and furnished with their personal possessions. Inspection of the building revealed that bedrooms had been equipped with individual furnishings that met the requirements for this standard. Where items listed in the standard were not included in the rooms, the manager stated that documentary evidence had been obtained from the individual service user to confirm that they were in approval with this. All rooms were carpeted or fitted with cushion flooring (only in rooms where severe incontinence problems were evident) with locks fitted to the doors and keys supplied upon request (one room is without a lock due to the needs of the occupant). Rooms were clean and comfortable and suited the service users needs. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Rooms were adequately ventilated with thermostatic controls in each room to regulate the central heating. Pipe work and radiators were guarded, and the water was both stored and released at the appropriate safe temperatures. Safe practices were based on policies and procedures and evidence indicated they were fully understood and followed by staff.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home was found to be clean, odour free and welcoming. The laundry is sited in the cellars of the house and had impermeable floors and walls. The washing machines had programmes to deal with foul laundry and disinfection of laundry. Clear policy and guidance was available in respect of this area of practice. The home had an infection control policy, with personal protective equipment available for staff and cleaners and appropriate COSHH regulation instructions available for all cleaning materials.Hook HallPage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 4 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 4 13 491 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 529 X X X0 18 34 Key findings/Evidence Standard met? The above figures are based on the staffing levels recommended by the Residential Forum for newly registered homes. Discussion with the manager indicated that the staffing levels had been increased above those set by the previous regulatory authorities guidelines and that on the day of this inspection, and from examination of the duty rota for each day of the week, three care staff were on duty in the morning, three in the afternoon (until 10pm), and two waking night carers through the night. Evidence from this inspection indicated that the staffing levels were in excess of those recommended by the Residential Forum and above the minimum for this standard.Hook HallPage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 22 3 Key findings/Evidence Standard met? Inspection of staff files indicated that the home had an induction programme that met the specifications of the Training Programme for the Personal Social Services (TOPSS) and was delivered by the Care Sector Trust. Evidence indicated that four of the eighteen care staff employed had obtained a qualification that was at least an NVQ 2 or equivalent, and the manager advised the inspector that all other carers were enrolled on a course leading to this qualification. Information given to the inspector indicated that the home was on target in ensuring that 50 of its staff achieves this level of qualification by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Hook Hall subscribes to a specialist employment service (Peninsula) for all of its recruitment policies and procedures in order to ensure that service users are protected in this respect. Evidence was seen on staff files of application forms, job specifications, terms and conditions, training qualifications, medical declarations and references that had been followed up. Satisfactory Criminal Records Bureaux and positive identity checks were seen to be present, including those relating to the most recent member of staff employed. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? Discussion with the manager indicated she has engaged the services of the Care Sector Trust to deliver an induction package for staff that meets the Training for Personal Social Services specifications and that all staff have been involved in this. Inspection of staff files confirmed this and indicated that home had invested extensively in other training courses and that staff were registered for various NVQ programmes at Beverly College. Other documentation seen by the inspector indicated that staff had attended further training at Goole, Selby, and Hull colleges and that the manager had undertaken her NVQ 4 in Advanced Management in Care with Business Interactions in Hull. Discussion with the manager indicated that the home was planning to commence delivery of other specialist courses and that further ongoing training in the areas already identified were scheduled in for the oncoming year. Hook Hall Page 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 4 Key findings/Evidence Standard met? The manager trained as a nurse and has had many years of experience in caring for the service user group accommodated at Hook Hall. Discussion with her indicated that she maintains relevant and periodic training, has the competence and skills required for the position, has obtained the Advanced Management in Care award and is currently undertaking the Registered Managers Award. Information given to the inspector indicated that she also holds an NVQ in training and development and holds a teaching certificate assessors award. There were clear lines of accountability within the home with a staffing structure, which includes manager, senior carers and cares. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? From discussion with the service users, evidence indicated that the management style in the home was open, positive and inclusive. The inspector saw records of regular staff and `Client meetings occurring, with actions taken and input into them by all concerned. Hook Hall has produced its own newsletter, that has details of forthcoming events, updates and information concerning the home and includes contributions from service users. Daily consultation with service users, service users meetings, staff meetings, a quality assurance system, and written and verbal opinion polls were some of the methods used by the home to obtain stakeholders opinions about the way in which the service is delivered, or possible changes proposed. The home had an equal opportunities policy, which covered staff and service users.Hook HallPage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? Discussion with the manager indicated that the home had a system in place for monitoring the quality of its service provision. Quality Assurance System, which involves a yearly calendar of areas and issues to audit. Questionnaires were seen that were given to service users, relatives, etc in order to obtain their opinions, and monitor the care, standards of accommodation, hygiene and safety, etc. There was a policy on quality assurance and the results of each survey fed back to service users at their meetings. However the home had not yet published the findings of its audits and the registered person must ensure this is achieved in order to fully meet this standard. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? Evidence indicated that the requirements of the previous inspection had yet to be implemented. The inspector saw evidence of satisfactory insurance cover for the home to the value of £5M that was renewed in August 2003 through Norwich Union. The homes viability was assured, and Clough and Company Accountants (Bradford) undertake regular audits of the accounts. However, the business plan for the home was not seen on this occasion. Discussion with the registered person indicated that this was maintained, but not reviewed each year and only as the bank requested. However, in order to fully meet this standard, the registered person must ensure that written proof of this is made available for inspection annually.Hook HallPage 32 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 1 X X3 Key findings/Evidence Standard met? Evidence indicated that the home had a policy of encouraging service users to be in charge of their finances wherever possible. The manager stated that the present service users managed their financial affairs or had them attended to by their families. Discussion with the manager indicated that no monies were held by the home and that the home usually paid for expenses incurred by service users, such as shopping and hairdressing, and then invoiced the relative dealing with the individuals finances. The manager advised that the home did not keep any valuables for the service users and that these would be recorded and signed for, in the event that an item was handed over for temporary safekeeping.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Inspection of the homes records indicated that staff were appropriately supervised. Discussion with the manager indicated that the home subscribed to a specialist employment service for the provision of recruitment and selection advice and information. Staff files indicated that formal supervision occurred on a two monthly basis, and this covered practice issues, philosophy of care and the staff members career development. Evidence was also seen of annual staff appraisals.Hook HallPage 33 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Evidence indicated that service users rights and best interests were safeguarded by the homes record keeping policies and procedures. Files were stored securely and discussion with service users indicated that they could have access to their records. The home had a Data Protection procedure for the management and staff to follow concerning all aspects of this area of practice. Records held for the protection of service users included an accident book, risk assessments, checks of equipment and the fire system together with various personal assessments for determining care needs, complaints, recruitment and selection of staff. The home had a policy on service users right to access their records and the Hull & East Riding Vulnerable Adults Procedure. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Hook Hall had a health and safety policy statement and inspection of the home indicated it to be well maintained, in order to ensure the safety of service users and staff. Documentation seen by the inspector and discussion with staff and management indicated that training was given in moving and handling (for which there is an assessor on site) fire safety, first aid and health and safety. Other courses in food hygiene and healthy eating had been accessed by the home from Goole College. Inspection of the records seen indicated that appropriate maintenance of fire equipment, gas and electricity was being followed and checked by approved engineers with certificates obtained. COSHH regulations were held on products and followed by staff, while personal protective equipment was available for use. Inspection of the hot water temperature indicated it to be delivered at appropriate temperatures.Hook HallPage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureHook HallPage 35 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Hook HallPage 36 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required Action plan was received at the point of publication Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: enter details here YES YES NOHook HallPage 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments:E.3.1 I, James Douglas Ford of Hook Hall confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these.Print Name Signature Designation DateHook HallPage 38 Hook HallPage 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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