Inspection on 01/11/06 for Hoyland Hall

This inspection was carried out on 1st November 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

Hoyland Hall 27/09/05

Hoyland Hall 10/06/05

Hoyland Hall 17/11/04

Hoyland Hall 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Hoyland Hall Market Street Hoyland Barnsley South Yorkshire S74 0EX Lead Inspector Bob Burkinshaw Key Unannounced Inspection 10:30 1st November 2006 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 Hoyland Hall DS0000006485.V291439.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. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hoyland Hall Address Market Street Hoyland Barnsley South Yorkshire S74 0EX 01226 745480 01226 742622 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) Healthmade (Hoyland Hall) Limited Mrs Cherryl Michelle Hayles Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The 40 beds may instead be used for PD - Physical Disability, for persons 60 years and above where the physical disability is related to the aging process. Staffing must be provided at, at least, the levels specified by `Residential Forum Care Staffing in Care Homes for Older People` published April 2002. The Manager’s hours (37 per week) must be over and above those specified at Condition 2. 27th September 2005 Date of last inspection Brief Description of the Service: Hoyland Hall is a care home providing personal care and accommodation for 40 older people. The homes registered owner is Healthmade (Hoyland Hall) Limited. Hoyland Hall is situated off the main road, close to the town centre at Hoyland, Barnsley, giving easy access to all local amenities and shops. The home is a two-storey building standing in its own grounds and has a garden area that is accessible to residents. There are car-parking facilities at the front of the building. The weekly fees are £315; if carers or prospective residents require further information about the home they can ask for a copy of the home’s Statement of Purpose or the service user guide provided by the owners. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours from 10:30am to 14:30pm. A tour of the premises took place and samples of records were examined. Care practices were observed. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to the manager and two of the staff on duty about their knowledge, skills and experiences of working at the home. Four residents were spoken with about their views on aspects of living at the home. Two relatives visiting the home were spoken with. Three residents satisfaction surveys were returned prior to the inspection, all three were very satisfied with the quality of their care at Hoyland Hall; five comment cards were returned by visiting professionals, they all commented positively about the care given to their patients at Hoyland Hall What the service does well: What has improved since the last inspection? Care plans now contain all the required information. The numbers of staff and staffing hours are sufficient to meet the needs of the residents. The home’s recruitment policy has improved. Staff training and supervision now takes place as required. The home receives a monthly quality assurance report from the owners. Hoyland Hall DS0000006485.V291439.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. Hoyland Hall DS0000006485.V291439.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 Hoyland Hall DS0000006485.V291439.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): 1, 2, 3, 4 and 5. National Minimum Standard 6 does not apply to Hoyland Hall Quality in this outcome area is good. This judgement has been made using available evidence including looking at recent admissions; speaking with residents and their visitors and reading individual resident files. EVIDENCE: The home’s statement of purpose and service user guide was available and in place. Each resident had been provided with an information pack, which included copies of a service user guide. The notice board at the entrance still refers to the former ‘nursing home’ function of Hoyland Hall. Contracts were in place for all residents and they contained the required information except where the private fee payers contract did not identify who was responsible for the payment of fees, whereas those contracts for residents financed by local authority contributions did. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 9 The inspector examined the files of five most recent admissions to Hoyland Hall; each file showed that the registered manager undertook a needs assessment with the prospective service users prior to admission. These assessments were kept in individual files with care plans. Access to specialists is provided to meet individual needs, e.g. chiropody services, optician and dental services. The staff have a range of experience and undertook training on a regular basis to ensure that they maintain the skills needed to care for residents. Residents confirmed that they had been able to look around the home, stay for a meal and meet other residents and staff before they moved in. The inspector spoke with four residents and they confirmed their satisfaction with the home; one resident said ‘I came for a look around with my family, the staff were very welcoming and that helped me make up my mind’. Two visiting relatives also spoke highly of the quality of care given. No resident is inappropriately placed. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 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 evidence including looking at the health care plans of the last five admissions to Hoyland Hall. Individual risk assessments were examined along the arrangements for the adminisitration and storage of medication at Hoyland Hall. EVIDENCE: Care plans were well indexed and included relevant information about the residents. Five care plans were inspected in depth and they contained a comprehensive range of information on personal, health and social care. The care plans are reviewed on a monthly basis and both residents and their relatives are involved in the annual review; the registered manager stated that local authority social workers rarely attend reviews now but prefer to participate by telephone. Risk assessments had been undertaken to promote safety. Documented risk assessments were in place in regard to the resident maintaining control of their keys and finances. The plan had been drawn up with the involvement of the resident and/or their advocate and agreed and signed by them. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 11 Staff could clearly state how they assisted residents with their personal care and residents said staff offered this appropriately as and when needed. Residents confirmed that access to health care professionals was available and their care plans recorded any necessary contact with GPs, chiropodists, dentists, opticians and district nurses. Systems were in place for the safe administration of medicines. The inspector observed staff signing administration records appropriately and these records were found to be up to date and accurate. All of the staff that administered medication had received training. No resident currently administers his or her own medication except one service user who retains an inhaler. Residents said their privacy and dignity was respected. Residents were wearing clean clothes and were well groomed. Both the visitors and the service users that spoke with the inspector said that the staff were ‘very good and kind’, visitors added that they were telephoned at home by staff to keep them informed. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 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 evidence including observing resident activities during the visit and discussing activity planning with the registered manager. The cook of the day was interviewed and a meal was observed. EVIDENCE: Care staff organise some activities with residents; these tend to be one-to one chats and weekly dominoes. Bingo nights and outside entertainers are also popular. Certain residents like to walk to the shops nearby. Church services take place on a regular basis. During this visit a number of residents chose to sit in either lounge where they were conversing with each other or staff, or were reading newspapers or watching television. Other residents chose to spend time in their rooms either reading or watching television and in two cases to receive visitors. All of the residents asked said that their visitors were able to come to the home when they wished, and they were able to see their visitors in private. One visitor said ‘I visit regularly, the staff always make me feel welcome’. Relatives are involved and encouraged to assist with admissions and helping to personalise bedrooms. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 13 All of the residents spoken to say the food at the home is good. The homes menu was varied and alternatives were offered. The kitchen staff are aware of residents likes and dislikes, and special diets were catered for. The cooks realise that meals are often the highlight of the day for some residents and they make an extra effort at bank holidays when a special buffet and drinks are always served; on Mothers Day every lady resident had a posy on their table at mealtime. The food is supplied by the local butcher, baker, greengrocers and dairy; the registered manager feels that this is important as residents used the same suppliers when they were living in the community and their relatives still do. Diabetic diets are catered for and the menus are varied and amended to meet the wishes of residents. The food served for lunch was nicely presented and everyone commented on the good quality of the cooking. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 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 evidence and by examining the home’s record of complaints. No adult protection issues have arisen since the last inspection. EVIDENCE: The homes complaints procedure was on display in a communal area of the home. The home keeps a record of complaints and the record showed that no complaints have been received by the home since the last inspection. All staff have undertaken training in adult protection and the adult protection procedure is readily available for guidance an allegation or incident took place. No referrals or action have been necessary with regard to adult protection since the last inspection. Both the adult protection policy and guidance and the Complaints and Concerns policy and guidance were reviewed in April 2006. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence and by touring the premises; viewing resident’s bedrooms and asking resindents to comment on the quality of their accommodation at Hoyland Hall. EVIDENCE: The inspector toured the building as part of the inspection process. The home was clean and in the main well decorated and well maintained. The communal lounges and dining room were well decorated and appeared comfortable. The ground floor lounge had been identified as a smoking area since the last inspection but there have been problems in identifying how to create an area that would only be used by the two service users who are smokers. Hoyland Hall management operates a no smoking on the premises policy for staff and also ask that visitors don’t smoke; they will give consideration to becoming a complete non-smoking home when they no longer accommodate residents who do smoke. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 16 The dining area was large enough to cater for all residents. All areas of the home were accessible to people in wheelchairs. Sufficient bathing facilities were available. Bathrooms were clean and provided with soap and towels to control infection. Residents’ bedrooms were well decorated and well personalised. One new resident confirmed that she had selected a number of personal items including furniture to accompany her when she had moved in recently. All of the residents spoken with said that they were happy with their rooms and that the communal areas were comfortable. The home provides a portable telephone set and every bedroom is equipped with a compatible socket; one resident has a private telephone line. A kitchenette is available for visitors to prepare a drink or snack when visiting their relatives at Hoyland Hall. The grounds were well maintained and a patio area was provided for residents to enjoy. The laundry and kitchen contained sufficient equipment to meet residents’ needs. The kitchen is being refurbished before Christmas and it is hoped that the job will be completed within 2 days. The local Environmental Health services had carried out a food hygiene inspection earlier this year and were satisfied with the outcome. The woodwork on the front porch remains rotten in places with damaged paintwork. This was reported at the last inspection and the registered manager told the inspector that the handy man now has the paint and materials to remedy this. The carpet in the entrance area has been replaced and looks much smarter. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence and by examining the staffing rota at the home and checking on the recruitment, training and supervision of staff. EVIDENCE: The current weeks rota was available at the home and this showed that the home had sufficient staff on duty to meet the needs of the current number of 28 residents, (the rota includes the addition of a ‘floater’ available between 1100-1800 hours to cover the teatime catering duties). The registered manager confirmed that all other staff hold National Vocational Qualification level 2 and that they have enjoyed the home’s training programme. A staff training matrix is now in existence and it identified which staff have undertaken essential refresher training in areas such as food hygiene and first aid; moving and handling is due next. The levels of NVQ trained staff are over and above those required; the registered manager is planning to gain an accredited trainer award. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 18 Two new care staff have been recruited since the last inspection and the inspector saw their personnel files and confirmed that they had provided satisfactory references and a satisfactory Criminal Records Bureau check. Any gaps in the employment history of a candidate are now explored at interview where the candidate must provide a curriculum vita in addition to the completed employment application form. These files also contained the training records of each member of staff that indicated that both had successfully completed an in-house induction programme and that one was enrolled for National Vocational Qualification Level 2. Staff records show that they are receiving supervision at the required intervals. The registered manager stated that she manages a very settled staff team and this was confirmed by the staff list submitted as part of the Pre-inspection questionnaire. Residents spoken to during this inspection visit stated that the staff were kind and patient. The inspector saw that when staff were not carrying out care tasks they spent time amongst the resident group. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence and by examining the staffing rota at the home and checking on the recruitment, training and supervision of staff. EVIDENCE: Residents and staff spoke well of the manager and said that she was approachable and supportive. One resident recalled how she had improved in her health and physical condition since coming to the home a number of years ago due to the care organised for her by the registered manager and carried out by the staff team. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 20 The financial records of service users are now kept at the home; families provide monies for residents, these monies are booked in and as they are spent receipts are kept. The income, expenditure and balance for each resident is recorded; when these personal monies are low the staff contact the relative and additional monies are then paid in. No resident looks after their own financial affairs. The inspector was able to inspect the finance records of residents and checked one at random and found it to be accurate and up to date. Staff undertake training on a range of topics including moving and handling, first aid, food hygiene, health and safety and infection control; their presence and completion of these training modules is now recorded and tracked on a training matrix. Staff supervision, to support and inform staff, now takes place at the required frequency. The accident book is up to date and accident-recording sheets are filed on individual residents’ files. A tour of the building identified no fire exits were blocked indoors and hazardous substances were securely stored. Fire fighting equipment had been serviced and was in date. Fire safety training takes place as required and all staff now participate in practice drills at least twice a year, this is recorded in the fire safety log. The South Yorkshire Fire & Rescue Service inspected the home on 13/3/06 and was satisfied with their findings. Weekly fire alarm checks take place; room water temperatures are checked monthly and logged; gas and electrical inspections are up to date as was PAT testing. Lift and hoist service records and certificates were up to date and valid. A quality assurance system, to obtain the views of residents, their representatives and professional visitors to the home, is now in place. The homes owner visits at the required monthly interval and writes a report of their findings for the manager and residents. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 21 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 3 2 3 3 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 22 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 The environment must be well maintained at all times; The rotten woodwork and worn paintwork to the front porch of the home must be dealt with and improved. This remains an outstanding requirement from the inspection carried out on the 25/9/05. Timescale for action 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations The notice board advertising the home should be altered to accurately reflect the registration category of the home. The terms and conditions/contract for service users should include a breakdown of the fee and who is responsible for the payment of that fee. Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 23 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 Hoyland Hall DS0000006485.V291439.R01.S.doc Version 5.1 Page 24 - 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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