Inspection on 31/05/05 for Horsfall House

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Horsfall House 24/04/06

Horsfall House 05/01/06

Horsfall House 14/12/04

Horsfall House 05/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Horsfall House Windmill Road Minchinhampton Stroud Glos, GL6 9EY Lead Inspector Janet Griffiths Unannounced 31 May 2005 10:00 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 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. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Horsfall House Address Windmill Road Minchinhampton Stroud Glos GL6 9EY 01453 731227 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Minchinhampton Centre for the Elderly To be appointed Care Home with Nursing 42 Category(ies) of Old Age not falling within any other category registration, with number (22) of places Dementia (20) D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Temporary variation to admit one named person under 65 years of age on a respite care basis one week in every six. Date of last inspection 14 December 2004 Brief Description of the Service: Horsfall House is a purpose built home accommodating elderly people who need nursing care, residential care or dementia care. The Home also provides a day centre offering a range of facilities for the elderly residents of the local community and is also open to the residents in the home by arrangement.The Home is situated on the outskirts of the town of Minchinhampton near to the common.The accommodation is attractively furnished and maintained. A shaft lift accesses the upper floor to the nursing General unit, which consists of 18 single and 2 double rooms, all with en suite facilities. The Cotswold (EMI) Unit comprises 20 single en suite rooms.The main dining room is situated in the front of the Home next to the kitchen and its aim was to provide for all residents in the Home. However, this is now used mainly for the Day Centre, as residents in the Cotswold (dementia care) unit and General unit have become frailer and are not able to access this room easily, and are at present using the limited facilities on the units. There are plans in place to address this in the next programme of redevelopment, when new dining room facilities are proposed.There are several attractive garden areas also available to the residents, which include a walled garden where residents from Cotswold Unit can wander in safety and a summerhouse, a popular meeting place for residents and their families. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a half hours, on one day in May 2005. The newly appointed acting manager was present throughout the day. A brief tour of the premises was carried out and several rooms were seen when residents were visited. A number of residents, two relatives and some staff were spoken with during the inspection and a selection of care records and other documents were seen. What the service does well: What has improved since the last inspection? New sluice facilities have been fitted on each floor and further improvements are to be made within Cotswold Unit. A number of areas have been redecorated and have had new furnishings provided. A rolling programme is in place to replace all the beds for electrically operated ones and some new bed linen has also been recently purchased. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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 standard(s) 1 & 3 The admission process is well managed and residents are given clear information regarding the service. EVIDENCE: The Statement of Purpose and Service Users Guide is currently being updated to incorporate recent management and other changes. New residents spoken with in the general unit all had a copy of the service users guide in their rooms. Some had read this but all were aware of the document. From the assessments seen and speaking with staff, it was evident that the assessed needs of the residents are being met. Relatives and staff were spoken with, in addition to residents within Cotswold Unit where the residents all have mental health needs. Again through these conversations and the records seen it was evident that resident’s assessed needs are being met. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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 standard(s) 7 & 9 The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication procedures in this home are well managed promoting good health. EVIDENCE: The care records of two residents from each unit were looked at on this occasion. Each resident is fully assessed on admission and this is reviewed regularly. From this, individual care is planned which reflected the current needs of the resident although the daily records of one resident identified two problems with elimination and swallowing that were not reflected in care plans. Where possible reviews are completed with the resident or their representative although it was discussed that this is difficult on occasions. There were one or two records that were not signed and dated and it was discussed that it would be beneficial for staff development if senior nursing staff were to conduct a regular care plan audit to highlight areas such as these. There was evidence in the records and from conversations with staff and residents that outside agencies are referred to wherever necessary, for example dentist, eye clinic and the audiology department. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 10 Medication records were checked in each unit and were well maintained. The home has changed to the blister pack system of administration over the past year and staff reported that they find this is working satisfactorily. Safe medication procedures are in place in the home. The dispensing pharmacy recently carried out their own audit, a report was seen and all was found to be satisfactory. With new legislation related to disposal of unwanted medications the home have discussed this with their pharmacy and arrangements are in hand for the pharmacy to dispose of medicines for the home. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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 standard(s) 12,13,14 Links with the community are good and support and enrich residents’ social opportunities. Some social activities are being organised but do not always provide daily variation and interest for people living in the home. EVIDENCE: A limited number of residents’ are able to attend any social events/activities held in the day centre each day and posters advertising events are clearly displayed around the home. One resident spoken with related that she does attend the day centre at times but finds it quite tedious, especially ‘the crossword puzzle that takes nearly all day to complete’. She did however say that she enjoyed the exercises that ‘were good for her’. Monthly newsletters are also produced and residents spoken with enjoyed receiving these. Within Cotswold Unit, these are pinned to notice boards outside each room for relatives’ information and for a source of conversation. A new activities co-ordinator is about to be appointed for the day centre and within the general unit one of the care staff is employed for two hours a week to plan and facilitate some activities on this unit. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 12 The home has built up a source of people who visit the home regularly to provide a variety of entertainments. Regular outings are planned, the most recent being to a newly opened garden centre. One resident related that she had been out on this trip and enjoyed it but ‘it was very crowded and too expensive to buy anything’. Other residents related that the prefer to remain in the home and pursuing their own interests although several said how much they enjoyed spending time in the garden and one on Cotswold unit gained much pleasure through looking after the homes’ cat. Some residents stated that they attended regular communion. A number of residents go out regularly with their relatives. Activities within Cotswold unit, because of the client group and their short attention spans, tend to be ad hoc, individual and of short duration, whether it is a walk around the gardens, as one was doing, or staff always being present in the lounge areas, chatting to them and providing a stimulating environment. It was evident through talking with service users, their relatives and staff that residents are able to choose how and where they spend their days. Some remained in their rooms and others chose to sit in the lounges around the home. All are offered a varied menu each day and all spoken with expressed their satisfaction of the food provided, one stating that ‘she always tries to leave a little as she feels she is putting on weight’. Relatives are invited to join the residents’ at mealtimes if they wish and are always offered beverages when they visit. On the general unit there are also facilities provided for relatives’ to make their own drinks if they wish, which is especially helpful on occasions where relatives are at the home for long periods of time, or travel long distances. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 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 standard(s) 16 & 18 The home has a satisfactory complaints system with some evidence that residents that their views are listened to and acted upon. The home has procedures and staff training in place to ensure that vulnerable adults are protected to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: Residents relatives’ spoken with all knew who to speak to if they had any concerns and felt that if they raised any concerns that they were dealt with effectively. A complaints procedure is included in the service users guide and is displayed within the reception of the home. Sessions on abuse training have been organised for May and June this year. Nineteen staff have already attended and more are scheduled to attend the June session. Four of the senior management team have also attended a twoday course. The home has an adults protection procedure in place and all staff are made aware of the whistle blowing process and would feel quite confident to report any concerns they had. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: All areas seen during the course of the inspection were well maintained and in excellent decorative order. Residents’ rooms and the communal areas were comfortably and tastefully decorated and furnished. Many had personal items of furniture, photographs and ornaments etc which they had chosen to bring in with them, creating a homely and individual appearance to their rooms. Several spoken with stated how comfortable they were and that high standards of cleanliness were maintained. New armchairs and curtains had been purchased for the general unit lounge. New bed linen, to include jersey sheets, which were very soft to the touch, has recently been purchased and a rolling programme of bed replacement is underway to gradually replace all beds with electrically controlled beds to maintain residents’ independence where possible. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 15 New sluice machines had been fitted on each unit, and further facilities are planned for Cotswold unit. New industrial vacuum cleaners and cleaning products have been purchased and appear very effective. There is limited communal space in both units of the home and discussions have taken place in past inspections regarding additional dining space. Further building work is planned and all uses for this extension are currently being considered. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Although the home still has some need for bank/agency staff at times there is now a good match of well-qualified staff offering consistency of care within the home. The arrangements for induction of staff are good, with staff demonstrating a clear understanding of their roles. The home has a robust recruitment procedure in place to safeguard and protect the people living in the home the protection of people living in the home. EVIDENCE: Both units were at full occupancy during the inspection, i.e. twenty-two residents on the general unit and twenty on Cotswold unit. A registered nurse and six care staff were on-duty on the general unit and a registered nurse, four care assistants and a housekeeper were on-duty on Cotswold unit during the inspection. The senior nurse for the general unit was supernumerary on this occasion. The qualified nurses on Cotswold during the day were agency/bank staff but both had been in the unit many times and both were very familiar with the unit and the needs of the residents. In the past, Cotswold unit in particular has used a lot of agency staff but the home is gradually building up their own bank for continuity. The home still has health care assistant vacancies and vacancies for an evening domestic and laundry assistant but have recently had a recruitment drive to hopefully D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 17 improve this situation. There were adequate staffing levels on the day of inspection to meet the current needs of the residents. It was reported that 22 care staff have attained NVQ 2, with a total of 41 with an NVQ qualification. A number of staff are also doing or have completed NVQ 3. Thirteen staff are working towards NVQ 2. Robust recruitment procedures are in place. The files of all new staff appointed since the last inspection, were seen and all but one had all the required documentation. Just one was noted as having no record of interview. The home completes CRB checks through an umbrella body, which keeps the original CRB disclosure and forwards the number only, unless there is anything to disclose. Details of all recent training were discussed, and notices of future training were seen displayed. This included fire training, first aid, food hygiene and abuse training and medication updates for registered nurses. Staff are currently engaged in an audit of training needs in order for the acting manager to plan future training. Induction of new staff is carried out in partnership with Cirencester College. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 33 The acting manager has a clear development plan and vision for the home which she has effectively communicated to staff, residents and their relatives. She is well supported by her senior staff in providing clear leadership throughout the home with all staff demonstrating awareness of their roles and responsibilities. The systems for resident consultation in the home are good with evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: The acting manager has submitted an application form to the CSCI and is awaiting interview and approval as registered manager of the home. Staff spoken with confirmed that she was open and approachable and that trained staff appreciated the recent meeting held for them and the proposal of three monthly meetings. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 19 A quality assurance programme is in place and satisfaction surveys have recently been sent to the relatives of each resident and are currently being collated. The results will be seen at the next inspection. One item that has already been identified and is being acted on is lack of activities. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x x D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 7 12 Regulation 15.1 16(2)(n) Requirement Timescale for action 1/7/05 Care plans to be written to reflect all the care needs identified for each resident. Consult service users about the 1/9/05 programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including having regard to the needs of the service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 12 Good Practice Recommendations All care records must be signed and dated. Service users interests are recorded and they are given opportunities for stimulation through leisure and recreational activities inside and outside the home which suit their needs, preferences and capacities. D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 22 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 D51_D03_s16476_Horsfall House_v229773_310505_Stage4_U.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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