Inspection on 28/08/06 for Housteads

This inspection was carried out on 28th August 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Housteads 09/10/07

Housteads 26/01/06

Housteads 01/09/05

Housteads 24/09/04

Housteads 06/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Housteads 1 Richmond Park Grove Sheffield South Yorkshire S13 8HX Lead Inspector Janice Griffin Key Unannounced Inspection 28th August 2006 07:00 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.V303500.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 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 www.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.V303500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 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. Copies of the last Commission For Social care Inspection reports were kept in the entrance for service users and their families to read. The weekly fees range from: £296 to £326. This information was provided on the 28th August 2006. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 07:00 am to 14:30 pm. As part of the inspection process the inspector spoke to fifteen service users, four relatives, the district nurse, three staff and the manager and would like to thank all for their openness and participating in the inspection process. The inspector was pleased to note that all service users spoke positively of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the manager and staff whom they said were approachable, supportive and sensitive to their needs and feelings. The relatives and district nurse described the service as ‘excellent’. A number of records were examined which included, the pre-inspection questionnaire completed by the manager, three service users surveys, medication records, three-service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Feedback on the inspection was given to the manager before the inspector left the home. One complaint have been received about this home since the last inspection, the complaint was about the heating system at the home. The manager investigated the complaint and it was upheld. What the service does well: The environment is homely, friendly and welcoming. The relatives and district nurse said the service users were well cared for by the staff. They described the staff as being “very good” and very hard working. Service users were able to visit the home for trial periods. The manager said that she considers carefully the needs assessment for each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Clear information about contracts/terms and conditions, fees and extra charges was available in a format appropriate to each individual service user and their families. All service users attended a variety of social and leisure activities and these were based very much on the personal preferences of each individual. Feedback was being sought on a regular basis from service users and their families. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 6 Staff interacted well with each service user and it was obvious from discussions with the service users and the relatives that staff had developed positive relationships with them. The cook was familiar with the food likes and dislikes of service users. The inspector observed the breakfast and lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Most of the staff team are qualified and experienced to work with the needs of service users with special needs. Documentation and discussion with three staff showed that they have had training in the specialist area of work that they work in. Records were in the main well ordered and up to date and the manager was keen to ensure that any issues found were addressed. What has improved since the last inspection? 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.V303500.R01.S.doc Version 5.2 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.V303500.R01.S.doc Version 5.2 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): 2, 3 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with fifteen service users, four relatives, three staff and manager and a visit to the home. No service users have moved into the home without having his or her needs assessed, this ensures that care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. The service users and relatives confirmed that this helped them to get to know everyone at the home, which made them feel less anxious. Information about contracts/terms and conditions, fees and any extra charges were available in a format appropriate to the individual service user. This gives the service users information about the service they should receive at the home. Intermediate care is not provided at this home. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 9 EVIDENCE: The staff are qualified and skilled to meet the specialist needs of prospective service users. Each care plan reflected the needs of the individual service user, with regard to their cultural, religious, physical and social care needs of new service users. Detailed full needs assessments had been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. Service users and the relatives spoken to said at the time of the service users admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. Staff are prepared to visit the prospective service users at home to get to know them and answer any questions. Records checked and discussion with four relatives confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with fifteen service users, the district nurse, four relatives, three staff and a visit to the home. Service users were encouraged and supported by staff to make decisions. This protects the rights and well being of service users. Information in care plans was good; it gave the staff full knowledge of the service users physical, social, health care, religious and cultural needs. Risk assessments had been reviewed on a regular basis. This protects the service users from harm. There was evidence in the care plans to show that the service users and their families are involved with the care planning production and the review. This allows them to have a say in how their care needs will be met. The medication recording systems were up to date; and there were no gaps in the recording sheets. This is safe practice. A pharmacist had checked the home’s medication systems in April 2006 and no issues of concern were reported. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 11 EVIDENCE: Staff were observed knocking on bedroom doors and they waited to be invited in before entering. Three service users plans of care were checked. Each set out individual service users needs and the action required and taken by staff to ensure those needs were met. Discussion with three staff and the district nurse identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users weight was being checked on a regular basis. A range of aids to assist service users with mobility problems was provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. The risk assessments in care plans had been reviewed on regular basis. The care plans detailed the gender of staff that the service users wished to support them with their personal care; they also contained details of the service users religious and cultural needs. Service users and relatives had been involved with production of the care plans and the reviews. Systems were in place to ensure the safe storage, administration and disposal of medication. Records were kept of medication received, and disposed of. A pharmacist had checked the home’s medication systems in April 2006;no issues of concern were reported. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with fifteen service users, four relatives, three staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. Service users were supported with maintaining and developing contact with their family and friends, relatives said they were made welcome at the home. This creates a home that people want to visit. A good choice of food was offered to service users at breakfast and lunchtime. Six service users were being offered special diets on a regular basis. This promotes the health and wellbeing of service users. EVIDENCE: The aims and objectives of this home reinforced the importance of treating service users with respect. Service users confirmed that staff were extremely supportive and always encouraged them to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 13 The cook was familiar with the dietary needs of service users. The inspector observed the breakfast and lunch offered to service users the food provided was of good quality, served hot, well presented and a good choice of food was offered. Six service users were receiving special diets for health reasons. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with fifteen service users, four relatives, three staff, the district nurse and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. The complaints procedure was widely distributed and was highly visible within the home. This allows service users and their families a clear understanding of how to make a complaint. Service users were protected from abuse by the awareness of staff through training and the homes procedures. This protects the well being of service users. EVIDENCE: The complaints procedure was available for service users, visitors, relatives and staff. The manager confirmed that this would be available in alternative formats and languages should this be requested. The service users, district nurse and a relatives spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last inspection one complaint has been made to The Commission For Social Care Inspection about the home, the complaint was about problems with the central heating system. The manager investigated the complaint and it was upheld, the heating system was repaired following the complaint. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 15 The home ensures through training, supervision, reviews and quality monitoring that the care staff fully comply with the policies and procedures provided in relation to protecting and safeguarding the rights of service users. Staff had been made aware of the action to take in dealing with third party information. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is: adequate. This judgement has been made after discussion with fifteen service users, four relatives and using available evidence including a visit to the home. The home was clean and smelt fresh. Some area around the home had damaged decoration. This made the home look shabby in parts. The bedroom doors were fitted with locks. This promotes the privacy of service users. Some of the windows were ill fitting; this made parts of the home feel cold in the winter said the service users. EVIDENCE: The service users said that the home was always clean, well lit and there was always enough hot water. Some areas of the home had recently been redecorated but some areas still had damaged decoration. The bedroom doors were fitted with suitable door locks and lockable facilities were provided in all the bedrooms. Some rooms had ill-fitting windows; the service users said some rooms felt cold in the winter because of this. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 17 Appropriate seating had been provided outside for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms, assisted baths and showers were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities and a good supply of equipment was also available for those service users. All areas used by service users had an emergency alarm system. The home had a proactive infection control policy and they work closely with external specialists, e.g. the Health Authority, Environmental Health and their own staff to ensure infections are minimised. Clinical waste is properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is: good. This judgement has been made after discussion with fifteen service users, four relatives, three staff and using available evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The homes recruitment procedures were not adequate, as they did not protected the service users from harm. The home had a training and development plan and all staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 19 EVIDENCE: The service users and relatives said that there was always enough staff on duty and they were consistent. They said that the staff worked very hard and described them as “very caring, kind and understanding”. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Three staff files were checked; the files demonstrated that the recruitment processes had not been followed as required by the Care Homes Regulations. Criminal record checks had been done for all three staff. Two references had been obtained but gaps were noted in one staff’s member’s employment history. 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. Staff files checked and discussions with three staff and the manager confirmed that all staff had completed detailed induction training. 48 of the staff team were qualified to NVQ level 2. Staff were being formally supervised at the frequency required to fully ensure individual staff development and the monitoring of care practices Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 20 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, 35, 37 and 38. Quality in these outcome areas is: good. This judgement has been made after discussion with the manager, fifteen service users, four relatives and three staff and using available written evidence including a visit to the home. The service users, relatives and three staff spoken to said the manager was approachable and very professional. Service users and relatives surveys are completed six monthly, which ensures that the home is run in the best interest of service users. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. Service users case files were securely stored. A safe environment was provided in all parts of the home. This protects the health, confidentiality and welfare of the service users. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff said she was committed to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. 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. There was a quality assurance system, which sought the views of service users and relatives. The responsible individual visit the home on a regular basis a report is written following the visits. A copy of the responsible individuals monthly report is sent to the local office of the Commission For Social Care Inspection. No fire exits were blocked and hazardous substances were securely stored. The staff handle money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnessed all transactions. The accounts are audited annually. All records were available for inspection and up to date and securely stored. Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X 3 3 Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 Requirement All areas around the building with stained damaged decoration must be redecorated. This has been outstanding since 01/06/06. The windows at the home should be replaced with ones of a more modern design which fully close. This has been outstanding since 2004. A minimum of 50 of staff should be trained to NVQ level 2. Gaps in staff’s employment history must be explored. Timescale for action 01/12/06 2. OP24 23 01/12/06 3. 4. OP28 OP29 18 19 31/12/06 31/08/06 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.V303500.R01.S.doc Version 5.2 Page 24 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 © 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 Housteads DS0000002975.V303500.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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