CARE HOMES FOR OLDER PEOPLE
Housteads 1 Richmond Park Grove Sheffield South Yorkshire S13 8HX Lead Inspector
Janice Griffin Unannounced Inspection 26th January 2006 10:00 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 Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Housteads Address 1 Richmond Park Grove Sheffield South Yorkshire S13 8HX 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) 0114 269 2469 0114 254 0903 martha.grundy@sheffcare.co.uk Sheffcare Limited Ms Martha Buchanan Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Housteads is a purpose built 40-bed home for older people. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries etc). It is a bungalow type building. All the rooms are single rooms and it has a suitable number of lounges and dining rooms. The gardens are landscaped and it has a large car park. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 10:00 am to 15:15 pm. As part of the inspection process twelve-service users, four relatives and six staff, including the manager on duty, were spoken to. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with each service user who were obviously comfortable and at ease in the company of staff. The inspector would like to thank service users, the relatives, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection?
Several bedrooms have been redecorated, stained pillows replaced and the damaged equipment replaced/repaired. All the Mar sheets were signed to show whether medication had been given or not and hazardous substances were securely stored. The manager said that all the requirements made by the fire officer had been actioned. The staff said that the working practices of the contracted cleaners were now much better.
Housteads DS0000002975.V274519.R01.S.doc Version 5.1 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. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not checked at this inspection they were checked at the last one. EVIDENCE: Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 9. Service users received individual personal support that promoted their privacy, dignity and independence. The healthcare needs of service users had been regularly assessed and reviewed. Procedures were in place to closely monitor the health and personal care of each service user. Medication for external use was noted to be insecurely stored in a bedroom. EVIDENCE: Discussion with service users identified that a range of health professionals visited the home to assist in maintaining health care needs. All service users case files contained details of nutritional care needs and details of weight gain or loss. This maintains the service users health. Service users said they were treated with respect and their privacy was upheld which helped to make them feel comfortable and ‘at home’. The relatives interviewed spoke in glowing terms of the care provided at this home, they said that the staff were very professional and extremely caring. One service user that had been deemed capable to administer her own medication had left medication for external use insecurely stored in her bedroom. This could be a potential health and safety risk. Records were kept of medication received, and disposed of. A pharmacist had checked the home’s medication systems at regular intervals.
Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 10 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): 15. The service users said the most of the meals provided were in the main wholesome, appealing and well balanced. EVIDENCE: The service users said the food provided was “good and there was always plenty of it”. Three meals were offered each day and snacks and drinks were provided in-between meals. The staff had arranged several meeting with the service users to look at reviewing the menus. This is good practice. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 11 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): 17. The service users legal rights were protected. EVIDENCE: The manager said that several service users had their legal rights protected by their families or solicitors. She also said that if any other service users requested access to advocacy services then she would facilitate the service for them, if requested. The homes accounts had been audited. This is good practice Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 12 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, 24 and 26. All areas seen were homely, comfortable and fresh smelling. Bathrooms and bedrooms had the appropriate locks fitted to ensure the privacy of service users. Service users had access to communal areas that were homely and included domestic style furniture and fittings. All areas of the home checked were clean. Some rooms still need redecorating, some of the windows need replacing. One kitchenette had damaged unit doors. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 13 EVIDENCE: Since the last inspection several bedrooms had been redecorated, the manager confirmed that service users had been included in the decisions regarding colour schemes. Some rooms still had damaged decoration. Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Service users spoken to said they were satisfied with their bedrooms, which they were able to personalise this they said made their rooms comfortable and homely. All the service users had been offered a key to their bedroom doors. Some service users complained that the bedroom windows let in a lot of cold air. The home had an appropriate amount of sitting, recreational and dining space and there were sufficient rooms for a variety of activities to take place. Outdoor space and all areas of the home were accessible to people in wheelchairs. One kitchenette had damaged unit doors. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 14 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 and 29. The service users said they felt safe and that the staff were competent and knowledgeable. Relatives and service users consulted spoke very highly of the care provided by the staff, they also said that the staffing levels at the home were adequate. The recruitment procedures were robust enough to protect the welfare of service users. EVIDENCE: The service users said that there was always enough staff on duty. They added that staff worked very hard and described them as “very caring” “kind” “understanding” and added that staff treated them like human beings they were not intrusive and that you could have a joke with them. Three staff files were checked; the files demonstrated that a thorough recruitment process had been followed as required by the regulations. CRB checks had been done and two references were available in each staff file checked. No gaps were noted in staff’s employment history. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 15 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): 31,33,34,37and 38. Service users benefited from a home that is well run by the registered manager. The service users and staff said the manager was approachable and very professional. Service users were benefiting from the care given by welltrained staff. Records were in the main up to date, well organised and securely stored. The homes policies and procedures met the required standards. The management of services users finances exceeded the minimum standards. A safe environment was not provided in all parts of the home. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 16 EVIDENCE: Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. This will ultimately benefit the health and welfare of the service users. There was a quality assurance system, which sought the views of service users. Service user meetings took place regularly both at the home and at other Sheffcare venues. Service users said this made them feel involved in the running of the home and that they could influence the quality of the care offered. This ensures that the home is run in the best interest of service users. No fire exits were blocked and hazardous substances were securely stored, maintaining service users safety. Service users case files were securely stored. This safeguards the confidentiality of service users. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions and all transactions were witnessed by a second individual. The accounts were audited each year. This is very good management practice. Two wires were noted to be trailing outside they could be a potential hazard. Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 1 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 4 X X 3 2 Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 12,13 Requirement Risk assessments must be reviewed for those service users who are not keeping medication for external use securely stored. The windows at the home should be replaced with ones of a more modern design which fully close. Timescale for action 01/02/06 2 OP24 23 01/12/06 3 4 5 OP19 OP19 OP38 23 23 13 All areas around the building 01/06/06 with stained damaged decoration must be redecorated. The damaged kitchen doors must 01/06/06 be repaired or replaced. The trailing wires must be 01/02/06 secured to the wall. 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 Housteads DS0000002975.V274519.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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