CARE HOMES FOR OLDER PEOPLE
Hunningley Grange 327 Doncaster Road Stairfoot Barnsley South Yorkshire S70 3PJ Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 30th November 2005 09:30 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 Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hunningley Grange Address 327 Doncaster Road Stairfoot Barnsley South Yorkshire S70 3PJ 01226 287578 01226 287578 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) Mr Azad Choudhry Mrs Julie Scholey Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Hunningley Grange is a detached residence with a purpose built extension, registered to provide personal care for 36 residents. All accommodation and services are on the ground floor. The home is located in the centre of Stairfoot, approximately two miles from Barnsley town centre and situated on a main bus route. The home is within walking distance of a full range of shops ie chemist, newsagent, hairdressers, dentist, supermarkets, post office, health centre, cafes and fast food outlets. There is car parking at the front and side of the home. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 am to 2.30 pm. Most of the service users were seen during the inspection. Five service users, six staff and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
The majority of previous requirements had been met.
Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 6 Risk assessments had been carried out for all service users in relation to falls and nutrition. Activities available had increased and a clear record of activities offered to service users was maintained. Staff files required some further information, however a clear record to demonstrate that all staff had received a CRB check was being maintained. The manager has successfully been registered with the CSCI. Health and safety records were being maintained and accident records checked demonstrated that detailed records of accidents suffered by service users were being maintained and appropriate follow up action was being taken. 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. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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): 3. Service users were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission. Staff from the home also visited prospective service users prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. The home does not provide an intermediate care service. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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): 7, 8, 9 and 10. Service users received personal support, which promoted their privacy, dignity and independence. Service users physical and emotional needs were met. Daily records required more detail to ensure that the service users healthcare needs could be monitored. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. Since the last inspection the care plans had been reviewed to include risk assessments in relation to falls, nutrition and the administration of medication. Records of healthcare visits were maintained and these evidenced that other healthcare professionals, eg general practitioner, chiropodist and optician,
Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 10 were visiting service users on a regular basis. Service users confirmed that their healthcare needs were met and described in detail the visits that they received. Daily records were maintained of the service users physical and emotional health and the care that had been provided. One record checked recorded that there were concerns in relation to one service user who was self administering their medication. However, the record did not record any observation or subsequent action that had been taken and no review of the service users risks assessment had taken place, to confirm that the service user could continue to safely administer their medication. All service users seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. Service users confirmed that the staff “definitely” respected their privacy. There was a medication policy and procedure to ensure that staff adhered to safe practices. Medication checked was stored and had been administered appropriately. Staff had received medication training, all promoting the safe administration of medication to service users. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15. Routines with the home were flexible and service users were encouraged to spend their day as they wished. A programme of activities was in place that was appropriate for the needs of service users. Service users were able to receive visitors at any reasonable time. A good choice of menu was offered and specific dietary needs were catered for. EVIDENCE: There was a relaxed atmosphere within the home. Service users were observed to be following their preferred routines. Several service users were sitting in the lounges socialising with other service users whilst others had chosen to spend time in the privacy of their bedroom. The daily routines within the home were flexible. Several Service users said that they preferred to spend their day in the privacy of their bedroom to read, watch television and complete puzzle books.
Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 12 Activities including cooking, music to movement, quizzes and professional entertainment were provided. Records of activities that had taken place were maintained and demonstrated that activities were offered and available for service users on a regular basis. There was a good choice of menu provided and special dietary needs were catered for. The cook confirmed that menus were reviewed on a regular basis based on service users likes and dislikes. The lunch meal was observed. Table presentation was good and the meals served looked appetising and well presented. Service users said that they enjoyed their meals and described the food as “good” and “marvellous”. One service user described in detail the specific diet that she had required due to a health care problem, and how the staff had ensured that her dietary needs were met. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Since the last inspection one complaint had been received which had been dealt with appropriately. Service users stated that they were satisfied with the care provided and that they had no complaints. They confirmed that they were comfortable to talk to staff should they any concerns in relation to their care and described that manager and staff as “approachable” and “they will always listen”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. All staff had received Adult Protection training to enable them to identify and report any allegations or incidents of abuse to service users. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 23, 24 and 26. The home was clean, comfortable and well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was well maintained and pleasantly decorated. All furnishings were clean and presented a homely environment. The grounds were tidy, well maintained and safely accessible to service users. Several bedrooms were checked and all were clean and pleasantly decorated. All the rooms had been personalised by the service user with small items of furniture, photographs and mementoes, which encouraged service users to retain their own identity. Service users confirmed, “I like my bedroom”. One service user, who preferred to spend the day in her room, described in detail
Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 15 how she had requested a move to a larger bedroom and how the manager had accommodated this. All areas throughout the home were clean and tidy and a good level of cleanliness was maintained. Laundry facilities were sited away from food preparation and service users areas, to ensure that any soiled linen was not carried through areas where food was prepared and did not intrude on service users. Staff training records demonstrated that the staff had attended Infection Control training, to promote a hygienic environment to control the risk of infection. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 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. Sufficient and experienced staff was provided that met the assessed needs of service users. A training and development programme was in place. Staff received regular training to update their knowledge and competence. Staff files required some amendments to ensure that they included the required information. EVIDENCE: Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. The Staff were friendly, approachable and relaxed to talk about the care that they provided. All service users spoke positively about the staff team and described them as “kind”, “very nice” and “lovely”. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Discussions with staff and records checked demonstrated that staff had received a good range of training that included Moving and Handling, First Aid and Nutrition. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 17 Ten members of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of residents. The manager confirmed that the remaining staff was in the process of working towards an NVQ qualification. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. The files did not contain a full employment history or a recent photograph of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 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 and 38. Service users and staff benefited from the ethos, leadership and management approach. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager has recently been registered, but has worked at the home for several years, most recently as deputy manager. The manager appeared enthusiastic and committed to her new role. She confirmed that she had recently enrolled to undertake a NVQ Level four qualification. All service users
Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 19 and staff spoke positively about her abilities to manage the home commenting that she was “approachable” and “supportive”. The manager confirmed that relatives and service users were encouraged to comment about the service that was provided. However, there was no formal process, eg questionnaires, to enable service users and their representatives to comment about the service that was provided and to give them the opportunity to suggest areas of improvement. Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. Detailed Records of accidents and injuries were maintained to ensure that service users were provided with the appropriate observation and supervision required. In the main all areas seen were safe, well maintained and accessible to service users. Two fire doors were wedged open, which did create a potential fire risk. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X X 2 Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15,17 Requirement Daily Care records must be more detailed to ensure that service users healthcare needs can be monitored. Risk assessments muse be reviewed on a regular basis to reflect the changing needs of the service user. Staff files must include proof of the person’s identity, including a recent photograph. Staff files must include the full employment history of the employee and any gaps in employment must be accounted for. Residents, relatives and representatives must be consulted in a more formal way and the results of the consultation must be published. (Previous timescales not met). Fire doors must not be wedged open. Timescale for action 30/01/06 2. OP8 15 30/01/06 3. 4. OP29 OP29 19 19 30/01/06 30/01/06 5. OP33 24 01/02/06 6 OP38 23 30/11/05 Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 Page 22 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. Refer to Standard OP31 Good Practice Recommendations The manager should have a qualification at NVQ level four in management (or equivalent). Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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 Hunningley Grange DS0000018258.V264032.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
